GW1-2022-03770_Well Construction - GW1_20220404

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RESIDENTIAL WELL CONSTRUCTION RECORD
- North Carolina Department of Environment and Natural Resources-Division of Water Quality
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� WELL CONTRACTOR CERTIFICATION#3073 A j!
1.WELL CONTRACTOR: g. WATER ZONES(depth):
Rick Crane Top Bottom Top Bottom
Well Contractor(individual)Name Top Bottom Top Bottom
Crane Bros. Well Drilling Top Bottom Top Bottom
Well Contractor Company Name
Thickness/
248 Crane Circle 7. CASING: Depth Diameter Weight Material
Street Address TopO Bottom 55 Ft.6 1/4 SDR-2 PVC
Franklin NC 28734
Top Bottom Ftj
City or Town State Zip Code Top Bottom Ft1
828 i 524-4976
Area code Phone number 8. GROUT: Depth Material Method
2.WELL INFORMATION: : TopO Bottom20 Ft.benonite pumped
WELL CONSTRUCTION PERMIT#120221-D Top Bottom Ft.
OTHER ASSOCIATED PERMIT#(ff applicable) Top Bottom Ft.
SITE WELL ID#(ff applicable) 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply L�'I Top Bottom Ft. in. in.
DATE DRILLED03/14/2022 Top Bottom Ft. in. in.
TIME COMPLETED AM❑ PM
Top Bottom Ft. in. in.
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4.WELL LOCATION: : 10.SAND/GRAVEL PACK:
CITY: Franklin COUNTYMacon Depth size Material
Top Bottom Ft.
Shone Road. Beech Hollow 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 M°41 1 933.0000 ^DMS OR 3x.XXXXXXXXX DD 0 /55 I:Clav
LONGITUDE S3 0°25 '2,zos.a000 ^DMS OR 7x.XXXXXXXXX DD : 55 /505 1`granite
Latitude/longitude source: FPS Qropbgraphic map /
(location of well must be shown on a USGS topo map andattached to /
this form if not using GPS) l
5.WELL OWNER /
Thomas Crattv
Owner Name
Shone Rd. /
Street Address /
Franklin NC 28734
City or Town State Zip Code / ` : ' tj}
Area code Phone number
12. REMARKS:
6.WELL DETAILS:
a. TOTAL DEPTH:1005
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO Ile
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: 100 FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use^+^if Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PROV ED TO THE WELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land Surface'
'Top of casing terminated at/or below land surface may required 03/30/22
a variance In accordance with 15A NCAC 2C.0118. SIGNATURE OF CERTIFIEDI`W ELL CONTRACTOR DATE
e. YIELD(gpm): 3 METHOD OF TmrAiir Rick Crane
f. DISINFECTION:Type Amount PRINTED NAME OF PERSON CONSTRUCTING THE WELL
_.-�.. •-- .�r ^' :' ----• ..��..-. ,Y— ate• .-, _'�. __" `f '`
'-,Submit within 30 days of completion to Division of Water-Quality information Processing, ; Form GwAa
-9617 Rev.2/09
Mail Service Center, Raleigh;_-NC 27699 161,Phone.[phone] ',