383744_Well Construction - GW1_20100521

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Qualitt
WELL CONTRACTOR CERTIFICATION # 2312
1 WELL CONTRACTOR
Cris J, Bullins
Well Contractor (Individual) Name
Raymond Brown Well Company Inc
Well Contractor Company Name
STREET ADDRESS 1109 North Main Street
Danbury NC 27016
City or Town State
( 336 )_ 593-8239
Zip Code
Area code- Phone number
2 WELL INFORMATION
SITE WELL ID #(if applicable)
WELL CONSTRUCTION PERMIT# SAS032210-01
OTHER ASSOCIATED PERMIT#(if applicable)
3 WELL USE (Check Applicable Box) Residential
DATE DRILLED 4-23-2010
Water Supply 0
0 PM Ox
Surry
TIME COMPLETED 11.30 AM
4 WELL LOCATION
CITY Dobson COUNTY
2029 Zepher 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 o GPS o 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 Phillip Cave
STREET ADDRESS 2039 Zephur Road
Dobson NC 27017
City or Town State
( 336 )_ 366-0151
Zip Code
YES iV.D
FT
Area code - Phone number
6 WELL DETAILS
a TOTAL DEPTH 305
b DOES WELL REPLACE EXISTING WELL?
c WATER LEVEL Below Top of Casing 43
(Use "+" if Above Top of Casing)
d TOP OF CASING IS 1 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) 100 METHOD OF
44
f DISINFECTION Type Hth Amount 16 oz275
g WATER ZONES (depth)
From 275 To 276 From 292 To 293
From To From To
From To From To
7 CASING Thickness/
Depth Diameter Weight Material
From 0 To 125 Ft 61/4 SIR 2 PVC;
From To Ft
From To Ft
8 GROUT Depth Material Method
From 0 To 24 Ft Cement poured
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 60 Soil
60 123 Sand rock
123 305 granite
r—I, , ,-- _
rc r-' .v—g ti o 1
MAY
2 1 MO
inform.tinn Pror. Q .n, , i.y.,
J
DWQ/BOG
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 OWNER
gWWE,LL
4-27-2010
S ATURE OF CERTIFIED WELL C RACTOR 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