383745_Well Construction - GW1_20100521

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 Inc
Well Contractor Company Name
STREET ADDRESS 1109 N Main
Danbury NC 27016
City or Town State
( 336 )_ 539-8239
Zip Code
Area code- Phone number
2 WELL INFORMATION
SITE WELL ID #(if applicable)
WELL CONSTRUCTION PERMIT# JF042710-06
OTHER ASSOCIATED PERMIT#(if applicable)
3 WELL USE (Check Applicable Box) Residential
DATE DRILLED 5-19-2010
Water Supply 0
0 PM Ox
Surry
TIME COMPLETED 1.00 AM
4 WELL LOCATION
CITY Mount Airy COUNTY
2281 Pine Ridge Road
(Street Name Numbers Community Subdivision Lot No Parcel Zip Code)
TOPOGRAPHIC / LAND SETTING
0 Slope 0 Valley 0 Flat 0 Ridge 0 Other
(check appropriate box)
LATITUDE
May be in degrees
minutes, seconds or
in a decimal format
LONGITUDE
Latitude/longitude source 0 GPS 0 Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
5 WELL OWNER
OWNER S NAME Misti Thomas
STREET ADDRESS 2281 Pine Ridge Road
Mount Airy NC 27030
City or Town State
( )-
Zip Code
YES 0 NO
FT
Area code - Phone number
6 WELL DETAILS
a TOTAL DEPTH 445
b DOES WELL REPLACE EXISTING WELL'
c WATER LEVEL Below Top of Casing 58
(Use "+" if Above Top of Casing)
d TOP OF CASING IS I FT Above
Land Surface*
surface may require
2C 0118
TEST Sight
*Top of casing terminated at/or below land
a variance in accordance with 15A NCAC
e YIELD (gpm) 2 METHOD OF
331745
f DISINFECTION Type Hth Amount 16 oz
g WATER ZONES (depth)
From 150 To 151 From 400 To 402
From To From To
From To From To
7 CASING Thickness/
Depth Diameter Weight Material
From () To 198 Ft 61/4 SIR 2 PVC
From To Ft
From To Ft
8 GROUT Depth Material Method
From 0 To 20 Ft cement pouring
From To Ft
From To Ft
9 SCREEN Depth Diameter Slot Size Material
From To Ft in in
From To Ft in in
From To Ft in in
10 SAND/GRAVEL PACK
Depth Size Material
From To Ft
From To Ft
From To Ft
11 DRILLING LOG
From To Formation Description
0 45 Soil
45 120 sand and sand rock
120 445 granite
B-.e I- I § G R.-- I 1
u a ts.-,.. n i i' u a — ins
(vial` 2 i Z010
12 REMARKS
information Processing Unit
DWQ/BOG
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
5-10-2010
SIGNATUREOF RTIFIED WELL CONTRACTOR DATE
Chris J Bullins
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days Attn Information Mgt ,
1617 Mail Service Center — Raleigh, NC 27699-1617 Phone No [phone] ext 568
Form GW-la
Rev 3/07