380867_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
1109 N Main Street
Street Address
Danbury NC 27016
City or Town
( 336 ) 593-8239
Area code Phone number
State Zip Code
g WATER ZONES (depth)
Top 170 Bottom 173
Top 200
Top 309 Bottom 311 Top
Top Bottom Top
7 CASING Depth Diameter
Top 0 Bottom 59 Ft 6 1 /4
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Material
2 WELL INFORMATION Top 0 Bottom 20 Ft cement
WELL CONSTRUCTION PERMIT# SAS1 12409-01 Top Bottom Ft
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if appi.cable)
3 WELL USE (Check Applicable Box) Residential Water Supoly f�
DATE DRILLED 12-3-09
TIME COMPLETED 4 45 AM ❑ PM 11
4 WELL LOCATION
CITY COUNTY Surry
174 Bushy Fork Lane
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel Zip Code)
TOPOGRAPHIC / LAND SETTING (check aporopnate box)
❑Slope ❑Valley ❑ Flat 0Ridge ❑ Other
LATITUDE 36 " DMS OR 3x XXXXXXXXX DD
LONGITUDE 75 " DMS OR DD
Latitude/longitude source LJ,PS [TTopographic map
(location of well must he shown on a USGS topo map andattached to
this form if not using GPS)
5 WELL OWNER
Byron Bowman
Owner Name
Street Address
City or Town
( )
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 325
State Zip Code
b DOES WELL REPLACE EXISTING WELL? YES 0 NO LEI
c WATER LEVEL Below Top of Casing 40 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 vanance in accordance with 15A NCAC 2C 0118
e YIELD (gpm) 20 METHOD OF TEST siaht
f DISINFECTION Type hth Amount 8 OZ
Top Bottom Ft
Bottom 202
Bottom
Bottom
Thickness/
Weight Material
sdr 21 pvc
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
Top Bottom Ft
Top_Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
Size
Material
Formation Descnption
0 / 6 clay
6 / 53 sand rock
53 /325 granite
/
12 REMARKS
'LT IL,,.
frER 022010
W/T;w, t r si CI1i1N1
Ntocessing Unit
I DO HEREBY CER FIFY 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
12-3-09
SIGNATURE OF CER ?IFIED WELL C.NTRACTOR 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