388079_Well Construction - GW1_20101007

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality3
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
g WATER ZONES (depth)
Top 507 Bottom 508 Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7 CASING Depth Diameter Weight
Street Address Top Bottom 133 Ft 6 1 /4 sdr 21
Danbury NC 27016 Top Bottom Ft
City or Town
( 336) 593-8239
Area code Phone number
State Zip Code
Top Bottom Ft
8 GROUT Depth Material
2 WELL INFORMATION Top 0 Bottom 22 Ft
WELL CONSTRUCTION PERMIT# SASO6O910-01 Top Bottom Ft
OTHER ASSOCIATED PERMIT#(kf applicable)
SITE WELL ID #(if applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply ❑
DATE DRILLED 07-04-10
TIME COMPLETED 1 00 AM ❑ PM DI
4 WELL LOCATION
CITY COUNTY Surry
587 Maranon Way
(Street Name, Numbers, Community, Subdivision, Lot No Parcel, Zip 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 [Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5 WELL OWNER
Blaine Johnson
Owner Name
Street Address
NC
City or Town State Zip Code
(336 )
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 525
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO LEI
c WATER LEVEL Below Top of Casing 70 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) 30 METHOD OF TEST siaht
f DISINFECTION Type HTH Amount 16 oZ
Top Bottom Ft
9 SCREEN Depth Diameter
Top Bottom Ft in
Top Bottom Ft in
Top Bottom Ft in
10 SAND/GRAVEL PACK
Depth
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
Size
Material
pvc
Method
pour
Slot Size
m
in
in
Material
Material
Formation Descnption
0 /125 sand rock
125 /525 granite
•
/ nci 0 ®
-vIut nforrr,.,.
/
12 REMARKS
Dlivods 7G s,rtg Unrt
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
07-04-2010
SIGNATURE OF CER11JI IED WELL CONTRACTOR DATE
Chris J Bullins
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to Divislonyof Water Quality'=",Information Processing,
1617 Mad Service Center, Raleigh; NC 27699-161*ione (919) 80r6300
Form GW-la
Rev 2/09