388084_Well Construction - GW1_20101007

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2312
1 WELL CONTRACTOR
Chris J Bullins
Well Contractor (Individual) Name
Raymond Brown Well Co
Well Contractor Company Name
P O. Box 337
Street Address
Danbury NC 27016
City or Town State Zip Code
( 336) 593-8239
Area code Phone number
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT# JRWO8O91 O-07W
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(1f applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply ❑
DATE DRILLED 09-08-10
TIME COMPLETED 4 00 AM ❑ PM lY
4 WELL LOCATION
CITY COUNTY SUrrV
249 Bluebird Lane Mount Airy
(Street Name, Numbers Community Subdivision Lot No Parcel Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑ Slope [Walley ❑Flat
LATITUDE 36
LONGITUDE 75
❑ Ridge ❑ Other
"DMS OR 3x xxxxxxxxx DD
" DMS OR 7x XXXXXXXXX DD
Latitude/longitude source ❑GPS ❑Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5 WELL OWNER
Kern Smith
Owner Name
Street Address
NC
City or Town State Zip Code
(336 ) 710-5016
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 705
b DOES WELL REPLACE EXISTING WELL") YES ❑ NO CAI
c WATER LEVEL Below Top of Casing 80 FT
(Use "+" if Above Top of Casing)
d TOP OF CASING IS 1 FT Above Land Surface*
*Top of casing terminated at/or below land surface may require
a vanance in accordance with 15A NCAC 2C 0118
e YIELD (gpm) 2 1/2 METHOD OF TEST SIaht
DISINFECTION Type HTH Amount 12 OZ
g WATER ZONES (depth)
Top 660 Bottom 670
Top
Top
Bottom
Bottom
7 CASING Depth Diameter
Top Bottom 96 Ft 6 1/4
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth
Top 0 Bottom 20 Ft
Top Bottom Ft
Top Bottom Ft
9 SCREEN Depth
Material
E` q
tf k. ,
Top Bottom
Top Bottom
Top Bottom
Thickness/
Weight Material
sdr 21 pvc
Method
pour
Diameter Slot Size Material
Top Bottom Ft in
Top Bottom Ft in
Top Bottom Ft
10 SAND/GRAVEL PACK
Depth
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
0 /9
9 /90
90 /705
/
/
12 REMARKS
in
in
in in
Size
Material
Formation Descnption
clay
sand rock
granite
° CU1Q
,vrtic, "
Unit
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER
09-08-2010
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
Chris J Bullins
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
11.2 F.. r,.
Submit within 30 Elays of completion to' Division of Waterr,Quality - information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161 Phone (919),807-6300
3><a n;
Form GW-la
Rev 2/09