380860_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
Chns J Bullins
Well Contractor (Individual) Name
Raymond Brown Well Company Inc
Well Contractor Company Name
1109 N Main Street
Street Address
Danbury
g WATER ZONES (depth)
top 130 Bottom 132
Top 230
`f ,t;t;
0
Bottom 235
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7 CASING Depth Diameter Weight Material
Top 0 Bottom 88 Ft 6 1/4 sdr 21 pvc
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 0 Bottom 25 Ft cement pour
WELL CONSTRUCTION PERMIT# JE100909-13 Top Bottom Ft
OTHER ASSOCIATED PERMIT#(if applicable) Top Bottom Ft
SITE WELL ID #(if applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply [Jl'
DATE DRILLED 12-29-09
TIME COMPLETED 1 00
AM PMLI
9 SCREEN Depth Diameter Slot Size Material
lop 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 Surry Top Bottom Ft
Top Bottom __ Ft
❑Slope EValley ❑Flat ❑Ridge ❑Other 11 DRILLING LOG
(Street Name Numbers, Community, Subdivision, Lot No , Parcel Zip Code) Top Bottom Ft
TOPOGRAPHIC / LAND SETTING (check appropnate box)
Top Bottom Formation Descnption
LATITUDE 36 " DMS OR 3x XXXXXxxxx DD /
LONGITUDE 75 " DMS OR DD
/
Latitude/longitude source ❑GPS []topographic map 0 / 9 clay
(location of well must be shown on a USGS topo map andattached to /
this form if not using GPS) 9 /80 sand rock
5 WELL OWNER
BIII Bushy
Owner Name
Street Address
City or Town State Zip Code
( )
Area code Phone number WATER i1UnL.i i , i iON
Inform lion Piocessing Unit
/
80 /245 granite
/
/ FFRG)2?010
6 WELL DETAILS
a TOTAL DEPTH 245
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO G✓
c WATER LEVEL Below Top of Casing 66 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) 50 METHOD OF TEST siaht
f DISINFECTION Type hth Amount 8 OZ
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
12-29-09
SIGNATURE OF CERTIFIED 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 Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone [phone]
Form GW-la
Rev 2/09