383725_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 NC 27016
City or Town State Zip Code
( 336) 593-8239
Area code Phone number
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT# SAS091 109-02
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply ❑
DATE DRILLED 03-08-10
TIME COMPLETED 4 00
AM CI PML1T
4 WELL LOCATION
CITY COUNTY SUM/
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑ Slope ❑ Valley ❑ Flat ❑ Ridge ❑ Other
" DMS OR 3x XXXXxxxXX DD
" DMS OR 7x XXXxXXXXX DD
LATITUDE 36 °
LONGITUDE 75
Latitude/longitude source OGPS (]topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5 WELL OWNER
Joshua Jarrell
Owner Name
Old LowaaD Road
Street Address
NC
City or Town
3�)
Area code Phone number
6 WELL DETAILS
TOTAL DEPTH 365
a
b
c
d
e
f
State Zip Code
DOES WELL REPLACE EXISTING WELL? YES ❑ NO CAI
WATER LEVEL Below Top of Casing 100 FT
(Use "+" if Above Top of Casing)
TOP OF CASING IS 30 FT Above Land Surface*
*Top of casing terminated at/or below land surface may require
a vanance in accordance with 15A NCAC 2C 0118
YIELD (gpm) 5 METHOD OF TEST siaht
DISINFECTION Type HTH Amount 10 OZ
g WATER ZONES (depth)
Top 120 Bottom 122
3 3 b A @.i
Top 180 Bottom 185
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7 CASING Depth Diameter Weight Material
Top Bottom 34 Ft 6 1/4 sdr 21 pvc
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Material Method
Top 0 Bottom 26 Ft pour
Top Bottom Ft
Top Bottom Ft
9 SCREEN Depth
Top Bottom
Top Bottom
Top Bottom
Ft
Ft
Diameter
in
in
Ft in
Slot Size Material
in
in
in
10 SAND/GRAVEL PACK
Depth Size Material
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
0 /5
5 /28
28 /365
/
/
12 REMARKS
Formation Descnption
red clay
Granite
eF"
RJ1 nv 1 A /AM
r,
Prey" -'
u+
►ntornio 'nNivari3 r.,
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
03-08-2010
SIGNATURE CERTIFIED WELL CONTRACTOR DATE
Chris J Buihns
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