388077_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
Chns J Bullins
Well Contractor (Individual) Name
Raymond Brown Well Company Inc
Well Contractor Company Name
STREET ADDRESS 1109 North Main Street
Danbury NC 27016
City or Town State
( 336 )_ 593-8239
Zip Code
Area code- Phone number
2 WELL INFORMATION
SITE WELL ID #(if applicable)
WELL CONSTRUCTION PERMIT# SAS081310-01
OTHER ASSOCIATED PERMIT#(if applicable)
3 WELL USE (Check Applicable Box) Residential
DATE DRILLED 9-13-2010
Water Supply O
0 PM OX
Surry
TIME COMPLETED 1.3Q AM
4 WELL LOCATION
CITY Mount Airy COUNTY
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING
0 Slope 0 Valley 0 Flat 0 Ridge 0 Other
(check appropriate 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 WELL OWNER
OWNER'S NAME Thomas R Meador
STREET ADDRESS
NC 27030
City or Town State
(______)-
Zip Code
YES 0 NOX
FT
Area code - Phone number
6 WELL DETAILS
a TOTAL DEPTH 185
b DOES WELL REPLACE EXISTING WELL?
c WATER LEVEL Below Top of Casing 58
(Use "+" if Above Top of Casing)
d TOP OF CASING IS 1 FT Above
Land Surface*
surface may require
2C 0118
TEST sight
*Top of casing terminated at/or below land
a variance in accordance with 15A NCAC
e YIELD (gpm) 15 METHOD OF
f DISINFECTION Type hth
Amount 8 oz
g WATER ZONES (depth)
From 160 To 162 From To
From To From To
From To From To
7 CASING Thickness/
Depth Diameter Weight Material
From O To 107 Ft R1/4 sell' 21 pvc
From To Ft
From To Ft
8 GROUT Depth Material Method
From 0 To 20 Ft cement pouring
From To Ft
From To Ft
9 SCREEN Depth Diameter Slot Size Material
From To Ft in in
From To Ft in in
From To Ft in in
10 SAND/GRAVEL PACK
Depth Size Material
From To Ft
From To Ft
From To Ft
11 DRILLING LOG
From To Formation Description
0 60 sin!
60 100 sand rock
100 185 granite
12. REMARKS:
OCT U a LGiG
Infnrmahnr P-,-ir.ccinri I roil
nvJi'Igrsr
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTEDIIN ACCORDANCE WITH
15A NCAC 2C WELL CONSTRUCTION STANDARDS AND THATiA COPµY,OF THIS"
RECORD S BEEN PROVIDED TOO Li4E WELL OWNER
0 7 20-11)4-2010
SIGNATURE OF CEI1FIED WELL_GONTRACTOR DATE
"✓i+ilatiOi rroc,.IsSlfig Unit
Chris J Bullins DV'IQ/BOG
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn Information Mgt ,
1617 Mail Service Center — Raleigh, NC 27699-1617 Phone No [phone] ext 568
Form GW-la
Rev 3/07