382463_Well Construction - GW1_20100413

5 WELL OWNER
Jim Radford
Owner Name
Street Address
STArf
RESIDENTIAL WELL CONSTRUCTION RECORD
North Calohna Department of Environment and Natwal Resources- Division of Water Duality
WELL CON TRACTOR CERTIFICATION # 2312
1 WELL CONTRACTOR
Chris J. BulIins
Well Contractor (Individual) Name
Raymond Brown Well Company Inc
Well Contractor Company Name
g WATER ZONES (depth)
Top 115 Bottom 118
Top 360 Bottom 363
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
1109 N Matn Street 7 CASING Depth Diameter Weight Material
Street Address Top 0 Bottom 79__ Ft 6 1 /4 sdr 21 pvc
Danbury NC 27016 Top Bottom_ Ft
City or Town State Zip Code Top_ Bottom Ft —_—
( 336) 593-8239 8 GROUT Depth Material Method
Area code Phone one number P
2 WELL INFORMATION Top O Bottom 27 Ft cement pour
WELL CONSTRUCTION PERMIT# SAS1 12309-02 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
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply ftir
DATE DRILLED 01-05-2010
TIME COMPLETED 4 30 AM ❑ PM I.
4 WELL LOCATION
CITY
COUNTY Surry
White Buffalo Road
(Street Name Numbers Community Subdivision Lot No Parcel Zip Code)
TOPOGRAPHIC / LAND SETT ING (check appropnate box)
10 SAND/GRAVEL PACK
Depth Size Material
Top Bottom Ft
Top Bottom Ft
lopBottomFt
11 DRILLING LOG
❑Slope [Valley ❑Flat ❑Ridge ❑Other Top Bottom
LATITUDE 36 " DMS OR 3X XXXXXXXXX DD — /
LONGITUDE 75 " DMS OR DD
Latitude/longitude source LI,PS Utopographic map /
(location of well must be shown on a USGS topo map andattached to 9 / 70 sand rock
this form if not using GPS)
70 / 505 blue granite
Formation Description
0 /9 red clay
/ 4-.'"A rlt Lam.
/ !t , ^•a. ,aa
City or Town State Zip Code / /, _ i ,/ t,�,
( ) '1 0�
Area code Phone number 12 REMARKS 0( ,., f�c
6 WELL DETAILS '/i3r'Sr" `Stir_
a TOTAL DEPTH 505 J y t4h,7
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO mf
c WATER LEVEL Below Top of Casing 8 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) 10
DISINFECTION Type hth
ME [HOD OF TEST siaht
Amount 10 OZ
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 . --^
j\YLO 01-05-2010
SIGNATURE OF CER IED WELL CONTRACTOR DATE
Chris J Bullins
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone [phone]
Form GVV-la
Rev 2/09