380881_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
Well Contractor Company Name
STREET ADDRESS 1109 N Main
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# DB032509-01
OTHER ASSOCIATED PERMIT#(ff applicable)
3 WELL USE (Check Applicable Box) Residential
DATE DRILLED 09-16-09
Water Supply 0
0 PM 0x
Surry
TIME COMPLETED 5.00 AM
4 WELL LOCATION
CITY COUNTY
(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
ina decimal format
LONGITUDE
Latitude/longitude source o GPS u 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 Stewart Mcguire
STREET ADDRESS
City or Town State
( )-
Zip Code
YES 0 NOX
FT
Area code - Phone number
6 WELL DETAILS
a TOTAL DEPTH 625
b DOES WELL REPLACE EXISTING WELL?
c WATER LEVEL Below Top of Casing 64
(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) 1/2 METHOD OF
ea 8
f DISINFECTION Type hth Amount 12oz
g WATER ZONES (depth)
From 190 To 191 From To
From To From To
From To From To
7 CASING Thickness/
Depth Diameter Weight Material
From 0 To 143 Ft A 1/4 sdr 21 pvr.
From To Ft
From To Ft
8 GROUT Depth Material Method
From 0 To 20 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
0-9 clay
9-135 sand rock
135-625 granite
PNe I-- f a P,m rf Fr ram,
12. REMARKS. FEB 0 2 2010
Interneion Proc.essina Unit
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 T THE WELL •WNER
OVIIA4A11'n 09-16-09
SIGNATURE OF CERT F D 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