GW1-2022-03799_Well Construction - GW1_20220404

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w . RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 3073 A
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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 Bottom24 rt.61/4 SDR-2 PVC
Franklin NC 28734 Top Bottom Ft.1
City or Town State Zip Code
8( 28 524-4976 Top Bottom Ft.
Area code Phone number 8. GROUT: Depth Material Method
2.WELL INFORMATION: Topo Bottorr20 Ft.benonite pumped
WELL CONSTRUCTION PERMIT#021522-D Top Bottom Ft.
OTHER ASSOCIATED PERMIT#(if applicable) Top Bottom Ft.
SITE WELL ID#(ff applicable)6590076972 9. SCREEN: Depth ; Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply Top Bottom Ft. in. in.
DATE DRILLED03-15-22 Tap Bottom Ft. in. in.
Top Bottom Ft. in. in.
TIME COMPLETED AM❑ PM Y
4.WELL LOCATION: 10.SAND/GRAVEL PACK:
+
CITY: Franklin couNTYMacon Top Depth Size Material
Bottom �Ft.
Tessentee 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 57 DMS OR 3X.XXXXXXXXX DD 0 /24 i1 Clav
LONGITUDE 83 0°zz 139.2174 ^DMS OR 7X.XXXXXXXXX DD 24 /555 granite
Latitude/longitude source: QGPS Oropographic map /
(location of well must be shown on a USGS topo map andattached to /
this form if not using GPS) l
5.WELL OWNER /
Bob Rav /
Owner Name
/
Street Address /
Franklin NC 28734
City or Town State Zip Code
Area code Phone number
12. REMARKS:
6.WELL DETAILS:
a. TOTAL DEPTH:555
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO 9
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
P VIDED TO THE WELL OWNER.
d. TOP OF CASING IS FT.Above Land Surface*
'Top of casing terminated at/or below land surface may require 03/30/22
a variance in accordance with 15A NCAC 2C.0118. IGWATURE OF CERTIFIERWELL CONTRACTOR DATE
e. YIELD(gpm): 20 METHOD OF TESTAir i
Pick Crane I 1
f. DISINFECTION:Type Amount PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of`a0M1.1&1On to Division of=Water Quality Information Processing,3 Form GW-ia
=1617 Maki f Service Center,Raleigh,NC 27699 161,Phone: [phone] =` i Rev.2/09