GW1-2022-08228_Well Construction - GW1_20220530

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D
r RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
3073 A
WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: �:C NED g. WATER ZONES(depth):
Rick Crane Top Bottom Top Bottom
Well Contractor(Individual)Name MAY 3 Top Bottom Top Bottom
Crane Bros.Well Drillina �3IInA TOP Bottom Top Bottom
Well Contractor Company Name 1 ,a'a Thickness/
248 Crane Circle T. CASING: Depth Diameter Weight Material
Street Address Top 0 Bottom 24 Ft.6.25 SDR-2 PVC
Franklin. NC 28734 Top Bottom Ft.
City or Town State Zip Code
8( 28 524-4976 Top Bottum Ft.
Area code Phone number 8. GROUT: Depth Material Method
2.WELL INFORMATION: Top Bottom20 Ft,benonite pumped
WELL CONSTRUCTION PERMIT#2021-22375-9-11625 Top Bottom Ft.
OTHER ASSOCIATED PERMIT#(if applicable) Top Bottom Ft.
SITE WELL ID#(if applicable)7564-60-4644 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply Pr Top Bottom Ft. in. in.
DATE DRILLED4/25/2022 Top Bottom Ft. in. in.
TIME COMPLETED AM El PM[ Top Bottom Ft. in. in.
4.WELL LOCATION: 10.SAND/GRAVEL PACK:
Depth Size Material
cry:.Glenville COUNTYJackson Top Bottom Ft.
117 Knob Hill 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'9 ' 911.0000 "DMS OR 3X.XXXXXXXXX DD 0 /24 Clav
LONGITUDE 83 al-7 1697.0000 'DMS OR 7x.XXXXXXXXX DD 24 /905 Granite
Latitude/longitude source: FOS Qropographic map /
(location of well must be shown on a USGS topo map andattached to /
this form if not using GPS) l
5.WELL OWNER /
Jim McDonald /
Owner Name /
1281 Meriweather Dr. /
Street Address /
Watkinsville GA 30677 I
City or Town State Zip Code /
U /
Area code Phone number
12. REMARKS:
6.WELL DETAILS:
a. TOTAL DEPTH:905
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: 500 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'
'Top of casing terminated at/or below land surface may require �� P 5-27-22
a variance in accordance with 15A NCAC 2C.0118. SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): 20 METHOD OF TESTAir Rick Crane
L DISINFECTION:Type Amount PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to Division of==Water Quality Information Proc"essing, Form GWAa
;.1617.MaiFServtce Center,Raleigh,-NC 27699 161,,;Phone (919)-807=6300 - Rev.2/09
.,,.