382447_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 Co.
Well Contractor Company Name
P 0 Box 337
Street Address
g WATER ZONES (depth)
Top 160 Bottum 163 Top
Top Bottom Top
Bottom
Bottom
Top Bottom Top Bottom
Thickness!
7 CASING Depth Diameter Weight Material
Top 0 Bottom 141 Ft 6 1/4 sdr 21 pvc
Danbury NC 27016 Top Bottom Ft
City or Town
( 336 ) 593-8239
Area code Phone number
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT# SAS061209-01
State Zip Code
OTHER ASSOCIATED PERMtT#(d applicable)
SITE WELL ID #(if applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply 0
DATE DRILLED 01-27-2010
TIME COMPLETED 10 30 AM ri PM 0
4 WELL LOCATION
CITY COUNTY SUrrV
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropriate box)
❑Slope ❑Valley ❑Flat ❑Ridge ❑Other
LATITUDE 36
" DMS OR 3x XXXXXXXXX DD
LONGITUDE 75 " DMS OR 7x xxxxxxxxx DD
Latitude/longitude source ❑GPS propographic map
(location of well must tre shown on a USGS topo map andattached to
this form if not using GPS)
5 WELL OWNER
Mitch Allen / James & Elaine Demosev
Owner Name
Pleasant Pine Road
Street Address
City or Town
3�)
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 505
State Zip Code
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO Rf
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) 5 METHOD OF TEST siaht
f DISINFECTION Type NTH Amount 12oz
Submit within 30 days of completion to. Division of Water Quality - information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone [phone]
Top Bottom Ft.
8 GROUT Depth Material
Top 0 Bottom O Ft CatfY1e✓1a—
Top Bottom Ft
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 in 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 / 8 red clay
8 /90
Sc v.ck co c X(
90 /135 Shell Rock
135 / 505 Granite
12 REMARKS
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 1
_ -
tt
01;27-2010
SIGNATURE OF CERTIFIED WELL CONTRACTOR, DATE ,/
Chns J Bullins /r,,
PRINTED NAME OF PERSON CONSTRUCTFNG/T14E WELL"ua/
Y%v`� Bi
t I{LFottn GWr1a
Rev 2/09