383733_Well Construction - GW1_20100521

RESIDENTIAL WELL CONSTRUCT ION 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 130 Bottom 132
3
F p i' t it 63'
J
Top 300 Bottom 302
Top Bottom Top Bottom
Top Bottom Top Bottom
Well Contractor Company Name Thickness/
P 0 Box 337 7 CASING Depth Diameter Weight Material
Top Bottom 86 Ft 6 1/4 sdr 21 pvc
Danbury NC 27016 Top Bottom Ft
City or Town State Zip Code Top Bottom Ft
( 336) 593-8239
Area code Phone number 8 GROUT Depth Material Method
2 WELL INFORMATION Top 3 Bottom 23 Ft JL-wvU,,,. pour
WELL CONSTRUCTION PERMIT# DB030210-01 Top Bottom Ft
Street Address
OTHER ASSOCIATED PERMIT#(f applicable)
SITE WELL ID #(if applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply 0
DATE DRILLED 04-07-10
TIME COMPLETED 2 30 AM ❑ PM it
Top Bottom Ft
9 SCREEN Depth Diameter Slot Size Material
Top Bottom Ft in in
Top Bottom Ft in in
Top Bottom Ft in in
4 WELL LOCATION 10 SAND/GRAVEL PACK
Depth Size Material
CITY COUNTY SurrV Top Bottom Ft
110 Cosby Road Top_ Bottom Ft
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code) Top Bottom Ft
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑ Slope ❑ Valley ❑ Flat ❑ Ridge ❑ Other
LATITUDE 36
" DMS OR 3x XXXXXXXXX DD
11 DRILLING LOG
Top Bottom
LONGITUDE 75 " DMS OR 7x XXXXXXXXX DD 0 / 10
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
Paul Roberts
Owner Name
Street Address
NC
City or Town
(336 )
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 405
State Zip Code
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO pf
c WATER LEVEL Below Top of Casing 40 FT
(Use "+" if Above Too of Casing)
d TOP OF CASING IS 1 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) 3 METHOD OF TEST siaht
f DISINFECTION Type HTH Amount 10 OZ
10 /80
80 /405
/
/
/
12 REMARKS
Formation Descnption
clay
rock
granite
fr—iTh
MAY 2 i 2u
Iriforrit;,, _, sSaiy vim
s;vv.."ravv
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
C'wo 04-7-09
SIGNATURE OF t RTIFIED WELL CONTRACTOR DATE
Chris J Bulllns
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