GW1-2021-07511_Well Construction - GW1_20211116

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of,Water Quality
WELL CONTRACTOR CERTIFICATION# 3073 A
1.WELL CONTRACTOR: g. WATER ZONES(depth):
Rick Crane Top Bottom Top Bottom
Well Contractor(Individual)Name Top Bottom Top Bottom
Crane Bros. Well Drillina Top Bottom Top Bottom
Well Contractor Company Name
Thickness/
248 Crane Circle 7. CASING: Depth Diameter Weight Material
Street Address TopO Bottom 45 Ft.6.25 SDR-2 PVC
Franklin NC 28734 Top Bottom Ft.
City or Town State Zip Code Top Bottom Ft.
( 828 ) 524-4976
Area code Phone number 8. GROUT: Depth Material Method
2.WELL INFORMATION: Top 0 Bottom 20 Ft.benonite Pumped
WELL CONSTRUCTION PERMIT#2021-20998-9-10945 : Top Bottom Ft.
OTHER ASSOCIATED PERMIT#(if applicable) Top Bottom Ft.
SITE WELL ID#(if applicable)7564-68-1486 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply @f Top Bottom Ft. in. in.
DATE DRILLED 1 1/08/2021 : Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
TIME COMPLETED AM❑ PM le
4.WELL LOCATION: 10.SAND/GRAVEL PACK:
Depth Size Material
CITY.,.- . 2 ak/)011 t f— COUNTYJackson Top Bottom Ft.
166 Catfish Run Top Bottom Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) Top Bottom Ft.
TOPOGRAPHIC/LAND SETTING: (check appropriate box)
❑Slope []Valley ❑Flat ❑Ridge ❑Other 11. DRILLING LOG
Top Bottom Formation Description
LATITUDE 35 a]"11 1 207.0000 "DMS OR 3X.XXXXXXXXX DD 0 /45 Clay
LONGITUDE 83 0*7 '839.0000 ^DMS OR 7X.XXXXXXXXX DD 45 /480 Granite
Latitude/longitude source: pl&PS Oropographic map / I
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS) lPicniz
IV V lip-1 5.WELL OWNER /
Michelle Price / - NOV
Owner Name /
9798 Hiahwav 226 S. �,
Street Address UNII
Nebo NC 28761 i
City or Town State Zip Code /
Area code Phone number
12. REMARKS:
6.WELL DETAILS:
a. TOTAL DEPTH:480
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO
I DO HEREBY CERTIFY THAT:,THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use"+"if Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land Surface' j
'Top of casing terminated at/or below land surface may require 11/09/2021
a variance in accordance with 15A NCAC 2C.0118. SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm):20 METHOD OF TESTAir Rick Crane
f. DISINFECTION:Type Amount PRINTED NAME OF PERSON,'CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality- Information Processing, Form GW-1a
1617 Mail Service Center,Raleigh,NC 27699-161,Phone:[phone] Rev.2/09
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