383722_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 375 Bottom 376 Top
Top Bottom Top
Top Bottom Top
Well Contractor Company Name
P 0 Box 337 7 CASING Depth Diameter
Street Address
Top t'' Bottom 121 Ft 6 1/4
Danbury NC 27016 Top Bottom Ft
City or Town
( 336) 593-8239
State Zip Code
Top Bottom Ft
3 3?22'
Bottom
Bottom
Bottom
Thickness/
Weight Material
sdr 21 pvc
Area code Phone number 8 GROUT Depth Material
2 WELL INFORMATION Top 0 Bottom 25 Ft (_N
WELL CONSTRUCTION PERMIT# JF0421 10-01 Top Bottom Ft
OTHER ASSOCIATED PERMIT#(rf applicable)
SITE WELL ID #(ifapplicable)
3 WELL USE (Check Applicable Box) Residential Water Supply ❑
DATE DRILLED 05-07-10
TIME COMPLETED 5 00 AM ❑ PM afi
4 WELL LOCATION
CITY COUNTY SUrrV
2408Pineridae 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 Qropographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5 WELL OWNER
Sam Bryant
Owner Name
Street Address
NC
City or Town
(336 )
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 425
State Zip Code
b DOES WELL REPLACE EXISTING WELL? YES iRr NO ❑
c WATER LEVEL Below Top of Casing 53 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) 5 METHOD OF TEST slaht
f DISINFECTION Type HTH Amount 10 OZ
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 Size Material
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
0 /44
44 /115
115 /425
Formation Description
soil
sand rock
granite
/ g‘Ct
/ IA
2 s tlW
l 1 2010
l%� rratIGri ; �r,
/
12 REMARKS
utr�0i� e ,g unit
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 ,
05-07-10
SIGNATURE OF ERTIFIED WELL CONTRACTOR DATE
Chris J Bullins
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30,days of completion to. Division of Water Quality ; Information-PrOC sling,
1617 Mail Service Center, Raleigh; NC 27699=161, Phone `�[phone]? a "
Form GW-la
Rev 2/09