388082_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 0 Box 337
Street Address
Danbury NC 27016
City or Town
( 336 ) 593-8239
Area code Phone number
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT# DB32410-01
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply ❑
DATE DRILLED 08-09-10
TIME COMPLETED 4 45 AM ❑ PM NI
4 WELL LOCATION
CITY COUNTY Surry
Rockford Road
(Street Name, Numbers, Community, Subdivision Lot No Parcel Zp Code)
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑ Slope ❑ Valley ❑ Flat ❑ Ridge ❑ Other
LATITUDE 36 " DMS OR 3x XXXXXXXXX DD
LONGITUDE 75 " DMS OR 7x xxxxxxxxx DD
Latitude/longitude source ❑GPS Dfopographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5 WELL OWNER
Joseph Culler
Owner Name
Street Address
NC
City or Town
(336 )
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 425
State Zip Code
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO CAI
c WATER LEVEL Below Top of Casing 48 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 variance in accordance with 15A NCAC 2C 0118
e YIELD (gpm) 5 METHOD OF TEST siaht
f DISINFECTION Type HTH Amount 10 OZ
g WATER ZONES (depth)
Top 390 Bottom 393
Top Bottom
Top Bottom
7 CASING Depth
Top Bottom 148
Top Bottom
Top Bottom
8 GROUT Depth
Top 0 Bottom 22
Top Bottom
Top Bottom
9 SCREEN Depth
Top Bottom
Top Bottom
Top Bottom
Top Bottom
Top Bottom
Top Bottom
Diameter
Ft 6 1/4
Ft
Ft
Material
Ft
Ft
Ft
Diameter Slot Size Material
Ft in
Ft in
Ft in
Thickness/
Weight Material
sdr 21 pvc
Method
pour
m
in
in
10 SAND/GRAVEL PACK
Depth Size Material
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
Formation Descnption
0 /80 clay
80 /140
sand rock
140 /425 granite
/
12 REMARKS
()Pr n
" I LU1p
DvvCt>'�' :,:''n3 unit?:3
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
PROVIDE IJ TO THE WELL OWNER
SIGNATURE OF CER ffl-IED WELL CONTRACTOR
Chris J Bullins
08-09-2010
DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30,days of completaonTo Division`ofmWater Quality=V Informaton,,Prpcessing,.
1617 Mail Service Center, Raleigh, NC 27699-161, Pho a (919j 807-6300 «
opt x
Form GW-la
Rev 2/09