386251_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 Company INC
Well Contractor Company Name
STREET ADDRESS 1109 N Main
Danbury NC 27016
City or Town State
( 336 )_ 593-8239
Zip Code
Area code- Phone number
2 WELL INFORMATION
SITE WELL ID #(i( applicable)
WELL CONSTRUCTION PERMIT# JRW051410-02
OTHER ASSOCIATED PERMIT#(if applicable)
3 WELL USE (Check Applicable Box) Residential
DATE DRILLED 7-16-2010
Water Supply 0
0 PM Ux
Surry
TIME COMPLETED 3.30 AM
4 WELL LOCATION
CITY Dobson COUNTY
378 Hamblin Road
(Street Name Numbers, Community Subdivision Lot No Parcel Zip Code)
TOPOGRAPHIC / LAND SETTING
0 Slope 0 Valley 0 Flat 0 Ridge 0 Other
(check appropnate box)
LATITUDE
May be in degrees,
minutes, seconds or
in a decimal format
LONGITUDE
Latitude/longitude source o GPS u 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 Elizabeth Urquiza
STREET ADDRESS
City or Town State
( )-
Zip Code
YES 0 NO>i;
FT
Area code - Phone number
6 WELL DETAILS
a TOTAL DEPTH 285
b DOES WELL REPLACE EXISTING WELL?
c WATER LEVEL Below Top of Casing 66
(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) 40 METHOD OF
356251
f DISINFECTION Type hth Amount 12oz
g WATER ZONES (depth)
From 275 To 276 From To
From To From To
From To From To
7 CASING Thickness/
Depth Diameter Weight Material
From 0 To 51 Ft 61/4 sdr21 pvc
From To Ft
From To Ft
8 GROUT Depth Material Method
From 0 To 21 Ft cement pouring
From To Ft
From To Ft
9 SCREEN Depth Diameter Slot Size Matenal
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 10 ciay
10 44 sandy rock
44 285 granite R+a, ay. w maw .a
r a. Irk Aft),,,.
w
AUG ii ': /fi10
Information D...::::,:rig
Unit
DWQ/BOG
12 REMARKS
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
1; n l&/%�.� 7-16-2010
SIGNATURE OF CE I IFIED WELL CONTRACTOR DATE
Chris J Bullins
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