382458_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. Bullins
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
Area code Phone number
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT# JF021810-001
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply Ft
DATE DRILLED 03-01-2010
TIME COMPLETED 4 00
NC 27016
State Zip Code
AM CI PMLi
4 WELL LOCATION
CITY COUNTY Surry
463 Bravford Road
(Street Name, Numbers Community Subdivision, Lot No Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑Slope EValley ❑Flat ❑ Ridge ❑Other
LATITUDE 36 " DMS OR 3x XXXXXXXXX DD
LONGITUDE 75 " DMS OR DD
Latitude/longitude source ['CPS L. opographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5 WELL OWNER
Richard Layne
Owner Name
Street Address
City or Town
�)
Area code Phone number
6 WELL DE1AILS
a TOTAL DEPTH 510
State Zip Code
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO f '
c WATER LEVEL Below Top of Casing 60 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) 100 METHOD OF TEST siaht
f DISINFECTION Type hth Amount 10 OZ
3
g WATER ZONES (depth)
Top 509 Bottom 510 Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness)
7 CASING Depth Diameter Weight Material
Top 0 Bottom 90 Ft 6 1/4 sdr 21 pvc
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Material Method
Top 0 Bottom 24 Ft cement 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 Size Material
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
Formation Descnption
0 /6 clay
6 /84 sand rock
84 /510 granite
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12 REMARKS0/0
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
03-01-2010
SIGNATURE F CERTI4WELL 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]
or
Form GW-la
Rev 2/09