386239_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 Bullins
Well Contractor (Individual) Name
Raymond Brown Well Co
Well Contractor Company Name
P 0 Box 337
Street Address
Danbury NC 27016
City or Town
( 336) 593-8239
Area code Phone number
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT# JRW042810-01
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply ❑
DATE DRILLED 06-25-10
TIME COMPLETED AM ❑ PM ly
4 WELL LOCATION
CITY COUNTY SUrrV
(Street Name Numbers, Community, Subdivision, Lot No Parcel Zip Code)
TOPOGRAPHIC / LAND SETTING
❑Slope ❑Valley ❑ FIat ❑ Ridge
LATITUDE 36
LONGITUDE 75
(check appropnate box)
❑ Other
" DMS OR 3x XXXXXXXXX DD
° " DMS OR 7x xxxxxxxxx DD
Latitude/longitude source ❑GPS
(location of well must be shown on a
this form if not using GPS)
5 WELL OWNER
Josh Stanley
Qropographic 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 265
State Zip Code
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO IRf
c WATER LEVEL Below Top of Casing 62 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) 5 METHOD OF TEST siaht
f DISINFECTION Type HTH Amount 8 OZ
g WATER ZONES (depth)
Top 90 Bottom 91 Top
Top 220 Bottom 222 Top
Top Bottom Top
7 CASING Depth
Top n Bottom 80
Top Bottom
Top Bottom
Diameter
Ft 6 1/4
Ft
Ft
Bottom
Bottom
Bottom
t38 6239
Thickness/
Weight Material
sdr 21 pvc
8 GROUT Depth Material Method
Top O Bottom 21 Ft CuMe✓ — 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
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
0 /44
44 /73
73 /265
/
12 REMARKS
Size
Material
Formation Descnption
soil
sand rock
blue granite
MJG 2 20T
Information Prnraactinz Unit
DWQ/BOG
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
SIGNATURE OF
Chris J Bullins
06-25-10
TIFIED WELL CONTRACTOR DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit„within,30, dayspffcompletion to Dtvisiomof-Water Quality;F� information Processing; Form GW-la
-
1617 Mail°Service Center ,Raleigh; NG 27699-161, Ph ne °[phone]'. Rev 2/09