380884_Well Construction - GW1_20100202

❑Slope ❑Valley ❑ Flat
LATITUDE 36 °
LONGITUDE 75 " DMS OR DD
Latitude/longitude source L);PS DTopographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICA PION # 2312
1 WELL CONTRACTOR
Chns J. Bullins
Well Contractor (Individual) Name
Raymond Brown Well Comoanv Inc.
Well Contractor Company Name
1109 N Main Street
Street Address
Danbury NC 27016
City or Town State Zip Code
336 ) 593-8239
Area code Phone number
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT# SAS1 12309-02
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(rf applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply Gir
DATE DRILLED 01-05-2010
TIME COMPLETED 4 30 AM ❑ PM 5(
4 WELL LOCATION
CITY COUNTY SUrrV
White Buffalo Road
(Street Name, Numbers, Community Subdivision Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑ Ridge ❑ Other
" DMS OR 3x XXXXXXXXX DD
5 WELL OWNER
Jim Radford
Owner Name
Street Address
City or Town
1�)
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 505
State Zip Code
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO Ci
c WATER LEVEL Below Top of Casing 8 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) 10 METHOD OF TEST SIaht
f DISINFECTION Type hth Amount 10 OZ
0 t� 3
g WATER ZONES (depth)
Top 115 Bottom 118 Top 360 Bottom 363
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7 CASING Depth Diameter Weight Material
Top O Bottom 79 Ft 6 1/4 sdr 21 pvc
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Material Method
Top O Bottom 27 Ft cement pour
Top Bottom Ft
Top Bottom Ft
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
0 /9
9 /70
Formation Descnption
red clay
sand rock
70 / 505 blue granite
/
/
/ CIO U 201(
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12 REMARKS
Ifiinrrn s,,,„ r�_,.__ _ ' fUN
..ny VIHL
1 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 OWNER2u164,
01-05-2010
SIGNATURE OF CERTIFIE ELL CONTRACTOR 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