388068_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 Company, Inc
Well Contractor Company Name
STREET ADDRESS 1109 North Main
Danbuy 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# SAS060410-10
OTHER ASSOCIATED PERMIT#(if applicable)
3 WELL USE (Check Applicable Box) Residential
DATE DRILLED 8-26-2010
Water Supply 0
0 PM Ox
Surry
TIME COMPLETED 4.30 AM
4 WELL LOCATION
CITY Mount Airy COUNTY
129 Callaway Road
(Street Name, Numbers Community, Subdivision, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING
D Slope 0 Valley 0 Flat 0 Ridge D 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 Robert Atkins
STREET ADDRESS
City or Town State
( 336 )_ 352-5625
Zip Code
YES 0 NO D
FT
Area code - Phone number
6 WELL DETAILS
a TOTAL DEPTH 245
b DOES WELL REPLACE EXISTING WELL?
c WATER LEVEL Below Top of Casing 55
(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) 10 METHOD OF
3
Y,i) L°
f DISINFECTION Type Hth Amount 12 0Z
g WATER ZONES (depth)
From 230 To 232 From To
From To From To
From To From To
7 CASING Thickness/
Depth Diameter Weight Material
From 0 To 94 Ft 61/4 SIR 9 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 50
20 88
88 245
12 REMARKS:
soil
sand rock
granit
oc.i 0 I /f11f
inrormatio q P„ t.-nssing Unit
OVVQ/c OG
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C WELL CONSTRUCTION STANDARDS AND THAT A COPY OF THIS
REC9 EyHAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF iTIFIED WELL CONTRACTOR
Chris J Bullins
8/31/2010
DATE
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