386238_Well Construction - GW1_20100812

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 BuIlins
Well Contractor (Individual) Name
Raymond Brown Well Co
Well Contractor Company Name
P 0 Box 337
Street Address
Danbury NC 27016
City or Town State Zip Code
( 336 ) 593-8239
Area code Phone number
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT# DE082108-70
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply ❑
DATE DRILLED 06-24-10
TIME COMPLETED AM ❑ PM I/
4 WELL LOCATION
CITY COUNTY SUM/
(Street Name, Numbers Community, Subdivision, Lot No , Parcel Zip Code)
TOPOGRAPHIC / LAND SETTING
❑ Slope ❑ Valley ❑ 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
Ray Freeman
" 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
a TOTAL DEPTH 165
State Zip Code
b DOES WELL REPLACE EXISTING WELLS YES ❑ NO IV
c WATER LEVEL Below Top of Casing 66
(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) 50 METHOD OF TEST siaht
f DISINFECTION Type HTH Amount 8 OZ
;Submit wlthm10 days of completion to. Division,of Water Quality - Information Processing
1617 MaitService Center; Raleigh, NC127699-161; Rhone', [phone]�
FT
336238
g WATER ZONES (depth)
Top 90 Bottom 91 Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7 CASING Depth Diameter Weight Material
Top Bottom 64 Ft 6 1/4 sdr 21 pvc
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Material Method
Top 0 Bottom 20 Ft C oAP-At - pour
Top Bottom Ft
Top Bottom Ft
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 Size Material
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
0 /30
Formation Description
soil
30 /56 sand rock
56 / 165 granite
/
12 REMARKS
2 'min
•••� rl{p'SSItl27 unit
- -
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
06-24-10
SIGNATURE OF RTIFIED WELL CONTRACTOR DATE
Chris J Bullins
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-la
Rev 2/09