383890_Well Construction - GW1_20100202

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 Company Inc
Well Contractor Company Name
STREET ADDRESS 1109 North Main Street
Danbury NC 27016
City or Town State
( 336 )_ 593-8239
Zip Code
Area code- Phone number
2 WELL INFORMATION
SITE WELL ID #(if applicable)
WELL CONSTRUCTION PERMIT# JE092509-13
OTHER ASSOCIATED PERMIT#(if applicable)
3 WELL USE (Check Applicable Box) Residential
DATE DRILLED 01-18-2010
Water Supply 0
0 PM Ox
Surry
TIME COMPLETED 1.00 AM
4 WELL LOCATION
CITY COUNTY
223 Shay Street Mt Airy NC 27016
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING
0 Slope 0 Valley 0 Flat 0 Ridge 0 Other
(check appropnate box)
LATITUDE
May be in degrees,
minutes, seconds or
in a decimal format
LONGITUDE
Latitude/longitude source 0 GPS 0 Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
5 WELL OWNER
OWNER'S NAME David Payne
STREET ADDRESS
City or Town State
(- )-
Zip Code
YES 0 NOR
FT
Area code - Phone number
6 WELL DETAILS
a TOTAL DEPTH 185
b DOES WELL REPLACE EXISTING WELL?
c WATER LEVEL Below Top of Casing 50
(Use "+" if Above Top of Casing)
d TOP OF CASING IS 1 FT Above
Land Surface*
surface may require
2C 0118
TEST sight
*Top of casing terminated at/or below land
a vanance in accordance with 15A NCAC
e YIELD (gpm) 30 METHOD OF
6)IP
1A
f DISINFECTION Type HTH Amount 8 OZ
g WATER ZONES (depth)
From 90 To 100 From To
From To From To
From To From To
7 CASING Thickness/
Depth Diameter Weight Material
From 0 To 50 Ft 6 1/4 Srir 91 PVC
From To Ft
From To Ft
8 GROUT Depth Material Method
From 0 To 21 Ft CEMENT POUR
From To Ft
From To Ft
9 SCREEN Depth Diameter Slot Size Matenal
From To Ft in in
From To Ft in in
From To Ft in in
10 SAND/GRAVEL PACK
Depth Size Matenal
From To Ft
From To Ft
From To Ft
11 DRILLING LOG
From To Formation Description
0-2 clay
2-44 sand rock
44-185 granite
II-t0-1 - -,' •/1e-I I
WATEF 11UALI I Y oct. , ION
Inform'tron Processing vim
12. REMARKS.
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
CA/ti—a t LC .,f� 01-18-2010
SIGNATURE OF ERTIFIED WELL CONTRACTOR DATE
Chris J Bullins
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days Attn Information Mgt ,
1617 Mail Service Center- Raleigh, NC 27699-1617 Phone No [phone] ext 568
Form GW-la
Rev 3/07