382465_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
Chns J. Bulllns
Well Contractor (Individual) Name
Raymond Brown Well Co.
Well Contractor Company Name
P 0 Box 337
Street Address
3
g WATER ZONES (depth)
Top 300 Bottom 302 Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7 CASING Depth Diameter Weight Material
Top Bottom 49 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
Area code Phone number 8 GROUT Depth Matenal Method
2 WELL INFORMATION Top 0 Bottom 22 Ft pour
WELL CONSTRUCTION PERMIT# SAS022510-01 Top Bottom Ft
OTHER ASSOCIATED PERMIT#(if applicable) Top Bottom Ft
SITE WELL ID #(if applicable) 9 SCREEN Depth Diameter Slot Size Material
3 WELL USE (Check Applicable Box) Residential Water Supply 0 Top Bottom Ft in in
DATE DRILLED 03-04-2010 Top Bottom Ft in in
TIME COMPLETED 4 00 AM 0 PM II Top Bottom Ft in in
4 WELL LOCATION
CITY COUNTY Surry
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑ Slope ❑ Valley ❑ Flat ❑ Ridge ❑ Other
LATITUDE 36
LONGITUDE 75 °
" DMS OR 3x xxxxxxxxx DD
" DMS OR 7x xxxxxxxxx DD
Latitude/longitude source DGPS ❑Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5 WELL OWNER
Darrell Mabe
Owner Name
2270 Quaker Church Road
Street Address
NC
City or Town State Zip Code
3�)
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 325
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO gOr
c WATER LEVEL Below Top of Casing 44 FT
(Use "+" if Above Top of Casing)
d TOP OF CASING IS 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) 1 0 METHOD OF TEST siaht
f DISINFECTION Type HTH Amount 10 OZ
10 SAND/GRAVEL PACK
Depth Size Material
Top Bottom Ft
Top_ Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
Formation Descnption
0 /9 red clay
9 /43
43 /325 Granite
12 REMARKS
i 11
'T
pry
10)
L Y
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
03-04-2010
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
Chns 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 GW-la
Rev 2/09