388085_Well Construction - GW1_20101007

NON 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 Company
Well Contractor Company Name
STREET ADDRESS 1109 N Main Street
Danbury NC 27016
City or Town State
)-
Zip Code
Area code- Phone number
2 WELL INFORMATION
SITE WELL ID #(if applicable)
WELL CONSTRUCTION PERMIT#(if applicable)
OTHER ASSOCIATED PERMIT #(if applicable)
3 WELL USE (Check Applicable Box) Monitoring
Industrial/Commercial❑ Agricultural❑ Recovery❑
Irngation0 Other! (list use)
JE081010-12
0 Municipal/Public0
Injection❑
DATE DRILLED 08-16-10
PMD
Surry
TIME COMPLETED 4 30 AMO
4 WELL LOCATION
CITY COUNTY
848 Quaker Church Road
(Street Name Numbers Community Subdivision, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING
❑ Slope 0 Valley 0 Flat 0 Ridge 0 Other
(check appropnate box)
LATITUDE
May be in degrees,
minutes seconds or
in a decimal format
LONGITUDE
Latitude/longitude source 0 GPS 0 Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
5 FACILITY- is the name of the business where the well is located
FACILITY ID #(if applicable)
NAME OF FACILITY
STREET ADDRESS
City or Town State Zip Code
CONTACT PERSON Chad Chilton
MAILING ADDRESS
City or Town State
( )-
Zip Code
YESO NOO
FT
Area code - Phone number
6 WELL DETAILS
a TOTAL DEPTH 805
b DOES WELL REPLACE EXISTING WELL?
c WATER LEVEL Below Top of Casing 48
(Use "+" if Above Top of Casing)
o
d TOP OF CASING IS 1 FT Above Land Surface*
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C 0118
e YIELD (gpm) 150 METHOD OF TESTTImed
f DISINFECTION Type hth Amount 16 oz
g WATER ZONES (depth)
From 305 To 306 From 385 To 386
From 800 To 801 From To
From To From To
7 CASING Depth Diameter Thickness/Weight Material
From 0 To 50 Ft 6 1/4 sdr 21 pvc
From To Ft
From To Ft
8 GROUT Depth Material Method
From 0 To 20 Ft cement poured
From To Ft
From To Ft
9 SCREEN Depth Diameter Slot Size Matenal
From To Ft in in
From To Ft in in
From To Ft in in
10 SAND/GRAVEL PACK
Depth Size Matenal
From To Ft
From To Ft
From To Ft
11 DRILLING LOG
From To Formation Description
0 12 soil
12 44 sand rock
44 805 granite
i-Sar
Inforrriafto,n i
12 REMARKS
i
DVVQ/st;r. g 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
08-16-10
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
Chris J Bullins
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days Attn Information Mgt ,
1617 Mad Service Center- Raleigh, NC 27699-1617 Phone No [phone] ext 568
Form GW-lb
Rev 12/07