382455_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. Bullies
Wet Contractor (Individual) Name
Raymond Brown Well Co
3 l t, '-f t' to
g WATER ZONES (depth)
Top 60 Bottom 62 Top
Top 408 Bottom 409 Top
Top Bottom Top
Well Contractor Company Name
P 0 Box 337 7 CASING Depth Diameter
Street Address
Danbury
City or Town
( 336 ) 593-8239
Area code Phone number 8 GROUT Depth Material
2 WELL INFORMATION Top 0 Bottom 29 Ft Ce(irl@.v'1Ar
WELL CONSTRUCTION PERMIT# J FO121 10-077 Top Bottom Ft
Bottom
Bottom
Bottom
Thickness!
Weight Material
sdr 21 pvc
Top_ 0 Bottom 48 Ft 6 1/4
NC 27016 Top Bottom Ft
State Zip Code Top Bottom. FL
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply ❑
DATE DRILLED 01-28-2010
TIME COMPLETED 2 30 AM ❑ PM Ll
4 WELL LOCATION
CITY COUNTY SUrrV
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING- (check appropiidte box)
❑ Slope ❑Valley ❑Flat ❑ Ridge ❑Other
LATITUDE 36 " DMS OR 3x xxxxxxxxx DD
LONGITUDE 75 " DMS OR 7x xxxxxxxxx DD
Latitude/longitude source ❑GPS []Topographic map
(location- of welt must be shown on a USGS tops -map at,th ttached to
this form if not using GPS)
5 WELL OWNER
Radford Hiatt
Owner Name
1206 Johnson Farm Road
Street Address
City or Town State Zip Code
(336 )
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 425
b DOES WELL REPLACE EXISTING WELL? YES V NO ❑
c WATER LEVEL Below Top of Casing 25 FT
(Use "+" if Above Top of Casing)
d TOP OF CASING IS A 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) 12 METHOD OF TEST Sight
DFSINFECTIO» Type I4TH Amount 14 oZ
Top Bottom Ft
Method
pour
9 SCREEN Depth Diameter Slot Size Material
Top Bottom Ft in in
Top Bottom Ft in in
Top Bottom Ft m in
10 SAND/GRAVEL PACK
Depth
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
Size
Material
Formation Descnption
0 / 6 red clay
6 /40
Scud c'ocK
40 /425 Granite
/
/
/
12 REMARKS
ohstor-,
� vGF
• 9 (kw
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
01-28-2010
SIGNATURE OF C ' TIFIED 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 GW-1a
Rev 2/09