382459_Well Construction - GW1_20100413

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. Buliins
Well Contractor (Individual) Name
Raymond Brown Well Company Inc.
Well Contractor Company Name
1109 N Main Street
Street Address
Danbury
City or Town
336 ) 593-8239
g WATER ZONES (depth)
Top 300 Bottom 303 Top
Top Bottom Top
Top Bottom Top
7 CASING Depth Diameter
Top O Bottom 54 Ft 6 1 /4
Top Bottom
NC 27016
State Zip Code
Area code Phone number
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT# SASO21810-01
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply (�
DATE DRILLED 02-26-2010
TIME COMPLETED 1 1 30 AM Pi PM D
4 WELL LOCATION
CITY COUNTY SUrrV
315 Simmons Grove Church Road
(Street Name, Numbers Community, Subdivision, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑Slope ❑Valley ❑Flat ❑Ridge ❑Other
LATITUDE 36 " DMS OR 3x xxxx0xxxX DD
LONGITUDE 75 " DMS OR DD
Latitude/longitude source LIGPS [Topographic map
(location of well must oe shown on a USGS topo map andattached to
this form if not using GPS)
5 WELL OWNER
Tracy Webster
Owner Name
Street Address
City or Town
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 425
State Zip Code
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO gr
c WATER LEVEL Below Top of Casing 30 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 vanance in accordance with 15A NCAC 2C 0118
e YIELD (gpm) 2 METHOD OF TEST siaht
f DISINFECTION Type hth Amount 10 OZ
Top Bottom Ft
8 GROUT Depth Material
Top 0 Bottom 21 Ft cement
3
Bottorn
Bottom
Bottom
Thickness/
Weight Material
sdr21 pvc
Top Bottom Ft
Top Bottom Ft
Method
pour
9 SCREEN Depth Diameter Slot Size
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 /5
5 /48
48 /425
/
12 REMARKS
Material
Size Material
Formation Descnption
clay
sand and sand rock
granite
hifr,„._
6'10
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
SIGMAi URE OFCERTI
Chris J Bullins
02-24-2010
IED WELL CONTRACTOR DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to' Division of Water Quality -
1617 Mail Service Center, Raleigh, NC 27699-161, Phone [phone]
Information Processing,
Form GW-la
Rev 2/09