GW1-2022-04690_Well Construction - GW1_20220512

&SIDENTL4L WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
" WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: f. DISINFECTION:Type Amount
Raymond C Brown
Well Contractor(individual)Name 9• WATER ZONES(depth):
From unknown To From To
Raymond Brown Well Company, Inc. From To From To
Well Contractor Company Name From To
From To
STREETADDRESS 1109 N Main 7. CASING:
Thickness/
Danbury NC 27016 Depth Diameter Weight Material
From—To �Ft.61/4 sd21 pvc
City or Town State Zip Code From To Ft.
3( 36 -593-8239 From To Ft.
Area code- Phone number
2.WELL INFORMATION: 8. GROUT: Depth Material Matte�riaal y Method
SITE WELL ID#(if applicable) From 0 To 6 Ft.C]A L—
I /y� n From To Ft.
WELL CONSTRUCTION PE MIT#j >qW1,"®(rlroti—03 From To Ft.
OTHER ASSOCIATED PE IT (if applicable)
9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check to o Residential Water Supply O From To Ft. in. in.
DATE DRILLED From To Ft. in. in.
TIME COMPLETED AMU PM OX From To Ft. in. in.
4.WELL LOCATION: // 10.SANDIGRAVEL PACK:
CITY: �e l5� �l,•r COUNTY v�, h Depth Size Material
From To Ft.
From To Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) From TO Ft.
TOPOGRAPHIC/LAND SETTING:
a Slope a Valley a Flat a Ridge a Other
(check appropriate box) 11.DRILLING LOG
LATITUDE May be in degrees, From To Formation Description
— — minutes,seconds or
LONGITUDE in a decimal format rx
Latitude/longitude source: a GPS o Topographic map
(location of well must be shown on a USGS topo map and swim I A 4 U22
attached to this form if not using GPS)
5.WELL OWNER ( I V
OWNER'S NAME r'`�J,'F-b
STREET ADDRESS _!llS
ly6 7 a
City or Town State Zip Code
33(6)- � " g S71
Area code- Phone number _
6.WELL DETAILS: )5 -
a. TOTAL DEPTH: — z(yyi —4 '-D 49n4
b. DOES WELL -EPLACE EXISTING WELL? YES a N0)9 Ir
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
��QQ 15A NCAC 2C,WELL CONSTRUCTIONISTANDARDS,AND THATA COPY OF THIS
c. WAftu;
E IOw Top Of Casing: FT. RECORD BEEN PR D TO THE WELL OWNE
--F"if Above Top of Casing)
d. TOP OF CASING IS FT.Above Land Surface'
'Top of casing terminated atlor below land surface may require SI NATURE O CERTIFIED WELL CONTRACTOR DATE
a variance in accordance with 15A NCAC 2C.0118.
e. YIELD(gpm): METHOD OF TEST sight PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn:Information Mgt., Form GW-1a
1617 Mail Service Center—Raleigh,NC 27699-1617 Phone No.[phone] ext 568. Rev.3/07