383736_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
g WATER ZONES (depth)
Top 270 Bottom 271 Top
Top Bottom 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
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT# JF022410-001
Top 0 Bottom 38 Ft 6 1/4
NC 27016 Top Bottom Ft
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply ❑
DATE DRILLED 05-5-10
TIME COMPLETED 12 30 AM ❑ PM NI
4 WELL LOCATION
CITY COUNTY SUrrV
Hardy 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
David Bowman
Owner Name
Street Address
NC
City or Town
(336 )
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 305
State Zip Code
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO Le
c WATER LEVEL Below Top of Casing 30 FT
(Use "+" if Above Top of Casing)
d TOP OF CASING IS 1 FT Above Land Surface*
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C 0118
e YIELD (gpm) 100 METHOD OF TEST siaht
f DISINFECTION Type HTH Amount 8 OZ
Top Bottom Ft
3 '7 3 6
Bottom
Bottom
Bottom
Thickness/
Weight Material
sdr 21 pvc
8 GROUT Depth Matenal
Top 0 Bottom 20 Ft CP-ti/ P yl
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 Description
0 / 3 Red clay
3 /30 sand rock
30 / 305 granite
/
12 REMARKS
MAY 2 i 201U
•: i r-rOCz:Ssing Unit
....„u1.,vFa
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
SIGNATURE OFjRTIFIED WELL CONTRACTOR DATE
05-05-10
Chris J Bullins
-c-64t4/o
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-la
Rev 2/09