383737_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
Well Contractor Company Name
P 0 Box 337
Street Address
Danbury
City or Town
( 336 ) 593-8239
Area code Phone number
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT# JRW121609-01
3
.257 eE 7
6 , 6
g WATER ZONES (depth)
Top 270 Bottom 274 Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7 CASING Depth Diameter Weight Material
Top Bottom 65 Ft 6 1/4 sdr 21 pvc
NC 27016 Top Bottom Ft
State Zip Code
OTHER ASSOCIATED PERMIT#(rfapplicable)
SITE WELL ID #(if applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply ❑
DATE DRILLED 05-14-10
TIME COMPLETED 12 30 AM ❑ PM NI
4 WELL LOCATION
CITY COUNTY SURRY
Rockford Road
(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 ❑Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5 WELL OWNER
Fred Susebach
Owner Name
Street Address
NC
City or Town
(336 )
Area code Phone number
6 WELL DETAILS
TOTAL DEPTH 305
a
b
c
d
e
DOES WELL REPLACE EXISTING WELL?
State Zip Code
YES ❑ NO W
WATER LEVEL Below Top of Casing 47 FT
(Use +" if Above Top of Casing)
TOP OF CASING IS 47 FT Above Land Surface*
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C 0118
YIELD (gpm) 6 METHOD OF TEST siaht
DISINFECTION Type HTH Amount 8 OZ
Top Bottom Ft
8 GROUT Depth
Top 0 Bottom 24 Ft
Top Bottom Ft
Top Bottom Ft
9 SCREEN Depth
Top Bottom
Top Bottom
Top Bottom
Ft in
Ft in
Ft m
10 SAND/GRAVEL PACK
Depth
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
Size
Material
Diameter Slot Size
in
in
Method
pour
in
Material
Material
Formation Description
0 /25 soil
25 /58 sand rock
58 /305 granite
/
12 REMARKS
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Information I-tocesstng unit
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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
PROVIDEDS� ��TO THE WELL OWNER •
\-�`AlkL" 1 .� `�x� �L J 05-14-10
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 - Informa ion Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone [phone]
Form GW-la
Rev 2/09