386244_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 State Zip Code
( 336 ) 593-8239
Area code Phone number
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT# SAS022410-02
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply D
DATE DRILLED 05-10-10
TIME COMPLETED 4 00 AM ❑ PM fI
4 WELL LOCATION
CITY COUNTY Surry
215 Storm Haven Lane
(Street Name Numbers Community Subdivision Lot No , Parcel Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropriate box)
❑Slope ❑Valley ❑ Flat ❑ Ridge ❑ Other
LATITUDE 36 0 " DMS OR 3x XXXXXXXXX DD
LONGITUDE 75 " DMS OR 7x XXXXXXXXX DD 0 / 40
Latitude/longitude source ❑GPS ❑Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
306244
g WATER ZONES (depth)
Top 345 Bottom 350 Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7 CASING Depth Diameter Weight Material
Top Bottom 70 Ft 6 1/4 sdr 21 pvc
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Material Method
Top 0 Bottom 25 Ft pour
Top Bottom Ft
Top Bottom Ft
9 SCREEN Depth Diameter
Top Bottom Ft in
Top Bottom Ft in
Top Bottom Ft in
10 SAND/GRAVEL PACK
Depth
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
5 WELL OWNER
Bill Norman
Owner Name
215 Storm Haven Lane
Street Address
NC
City or Town
(336 )
Area code Phone number
6 WELL DETAILS
TOTAL DEPTH 365
a
b
c
d
DOES WELL REPLACE EXISTING WELL?
State Zip Code
YES ❑ NO
WATER LEVEL Below Top of Casing 51 FT
(Use "+" if Above Top of Casing)
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) 15 METHOD OF TEST SIaht
f DISINFECTION Type HTH Amount 10oz
Submit within 30 days of completion to Division of Water Quality 7; Infor"matron Processing,
1617 Mail Service Center, Raleigh; NC 27699-161, Phone ,[phone]-
,e
40 /63
63 /365
/
/
12 REMARKS
Size
Slot Size Material
in
in
in
Material
Formation Description
Soil
sand rock
granite
bin 1 k -' -
�!eing Unit
Ini9r�Odon nn
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 CE
Chris J Bullins
FIED WELL CONTRACTOR
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-la
Rev 2/09