380877_Well Construction - GW1_20100202

( 336 ) 593-8239
Area code Phone number
2 WELL INFORMATION
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality 9 '
WELL CONTRACTOR CERTIFICATION # 2312
1 WELL CONTRACTOR
Chris J Bullins
Well Contractor (Individual) Name
Raymond Brown Well Co
g WATER ZONES (depth)
Top 140 Bottom 182
Top 375
Top Bottom Top
Top Bottom Top_
Well Contractor Company Name
P 0 Box 337 7 CASING Depth Diameter
Street Address
Danbury
Top 0 Bottom 70 Ft 6 1 /4
NC 27016 Top Bottom Ft
City or Town State Zip Code
Top Bottom Ft
8 GROUT Depth Matenal
Top 0 Bottom 20 Ft cement
WELL CONSTRUCTION PERMIT# SAS082809-08 Top Bottom Ft
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply Cl
DATE DRILLED 11-24-09
TIME COMPLETED 4 30 AM ❑ PM ❑
4 WELL LOCATION
CITY COUNTY SUrry
134 Green Valley Trail
(Street Name, Numbers, Community Subdivision, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑Slope ❑Valley ❑Flat ❑ Ridge ❑Other
LATITUDE 36 "DMS OR 3x XXXXXxxXX DD
LONGITUDE 75 " DMS OR 7x XXXXXXXXX DD
Latitude/longitude source ❑CPS [Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5 WELL OWNER
Joe Bishop
Owner Name
Street Address
City or Town
(336 )
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 405
State Zip Code
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO d
c WATER LEVEL Below Top of Casing 50 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) 4 METHOD OF TEST siaht
f DISINFECTION Type HTH
Amount 8 Oz
Top Bottom Ft
c5 r.
Bottom 380
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 Size Material
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
Formation Descnption
0 /6 clay
6 /64
sand rock
64 /405 granite
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12 REMARKS Inforrn;tion Processing 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
J14/111-24-09
SIGNATURE OF CERTIF D 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-1a
Rev 2/09