388080_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
Wet Contractor Company Name
P 0 Box 337
g WATER ZONES (depth)
Top 110 Bottom 112 Top
Top 240 Bottom 245 Top
Top Bottom Top
7 CASING Depth Diameter
Street Address Top Bottom 78 Ft 6 1/4 sdr 21 pvc
Bottom
Bottom
Bottom
Thickness/
Danbury NC 27016 Top Bottom Ft
City or Town State Zip Code Top Bottom Ft
( 336 ) 593-8239
Area code Phone number 8 GROUT Depth Material
2 WELL INFORMATION Top 0 Bottom 21 Ft
WELL CONSTRUCTION PERMIT# JEO51010-05W Top Bottom Ft
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply D
DATE DRILLED 08-06-10
TIME COMPLETED 3 30 AM ❑ PM E
4 WELL LOCATION
CITY COUNTY Surry
188 Mountain Escapade Trail
(Street Name Numbers Community Subdivision Lot No Parcel Zip Code)
TOPOGRAPHIC / LAND SETTING
❑Slope [Walley ❑Flat ❑Ridge
LATITUDE 36
LONGITUDE 75
(check appropnate box)
❑Other
" DMS OR 3x XXXXXXXXX DD
Latitude/longitude source ❑GPS
(location of well must be shown on a
this form if not using GPS)
5 WELL OWNER
Blaine Johnson
" DMS OR 7x XXXXXXXXX DD
[Topographic map
USGS topo map andattached to
Owner Name
Street Address
NC
City or Town
(336 )
Area code Phone number
6 WELL DETAILS
TOTAL DEPTH 765
DOES WELL REPLACE EXISTING WELL? YES ❑ NO CAS
a
b
c
d
e
WATER LEVEL Below Top of Casing 70
(Use "+" if Above Top of Casing)
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
State Zip Code
YIELD (gpm) 4 METHOD OF TEST siaht
FT
DISINFECTION Type HTH Amount 16 OZ
Top Bottom Ft
Weight Material
Method
pour
9 SCREEN Depth Diameter Slot Size Material
Top Bottom Ft in in
Top Bottom Ft in in
Top Bottom Ft in in
10 SAND/GRAVEL PACK
Depth
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
Size
Material
Formation Descnption
0 / 70 sand rock
70 / 765 granite
/
l r11, l
2f11f1
/
12 REMARKS
" "' v'bs^,rSn I Inea
a vvLub03
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
08-06-2010
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
Chris J Bullins
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit vrithms30�days;otcompietlon,to:z°Division=otWater:Qual'iW-
16171Mali Service Center; Raleigh, NCs27699-161, Phone, {919) 807-6300 ;
InformationgProce`sSmg,
Form GW-la
Rev 2/09