380873_Well Construction - GW1_20100202

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2080
1 WELL CONTRACTOR
Chris King
Well Contractor (Individual) Name
Raymond Brown Well Company
Well Contractor Company Name
STREET ADDRESS 1109 N Main Street
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# JE111309-143
OTHER ASSOCIATED PERMIT#(ff applicabie)
3 WELL USE (Check Applicable Box) Residential
DATE DRILLED 11-16-09
Water Supply 0
0 PM OX
aA.(,1 1
StEntalk
TIME COMPLETED 3.00 AM
4 WELL LOCATION
CITY COUNTY
766 Goner Road
(Street Name Numbers, Commun ty 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
in a decimal format
LONGITUDE
Latitude/longitude source 0 GPS 0 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 Steven Kish
STREET ADDRESS
City or Town State
( 336 )_ 325-3540
Zip Code
YES 0 NOX
FT
Area code - Phone number
6 WELL DETAILS
a TOTAL DEPTH 325
b DOES WELL REPLACE EXISTING WELL?
c WATER LEVEL Below Top of Casing 25
(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) 6 METHOD OF
9 L 4)
cB 1; Z,` a e�+
f DISINFECTION
g WATER
From 80
Type HTH Amount 5 Oz
ZONES (depth)
To 81 From To
From 300 To 301 From To
From To From To
7 CASING Thickness/
Depth Diameter Weight Matenal
From () To 34 Ft A 1/4 sdr 21 pvc
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 Material
From To Ft
From To Ft
From To Ft
11 DRILLING LOG
From To Formation Description
0-5 red clay
5-26 sand rock
26-325 blue granite
L M r 1� s o--
r—
it \ _ IIV u
f-L.k3 0 2 2010
12. REMARKS:
WAT% - , - 1 `NI
!mean,. ton Processing Unit
I DO HEREBY CERTIFY
15A NCAC 2C WELL
RECORD HAS BEEN
'Iri/l�/1
THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
CONSTRUCTION STANDARDS AND THAT A COPY OF THIS
PROVIDED TO THE WELL OWNER
11-16-09
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
Chris King
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days Attn Information Mgt.,
1617 Mad Service Center — Raleigh, NC 27699-1617 Phone No [phone] ext 568
Form GW-la
Rev 3/07