380865_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 Kina
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 State Zip Code
( 336) 593-8239
Area code Phone number
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT# SAS1 13009-01
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply yf
DATE DRILLED
TIME COMPLETED AM 0 PM fi
4 WELL LOCATION
CITY COUNTY SUrrV
(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 DD
Latitude/longitude source LAPS Ui opographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5 WELL OWNER
Candice Norman
Owner Name
Street Address
City or Town State Zip Code
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 305
b DOES WELL REPLACE EXISTING WELLS YES ❑ NO [f
c WATER LEVEL Below Top of Casing 58 FT
(Use "+" if Above Top of Casing)
d TOP OF CASING IS 1 FT Above Land Surface*
*Top of casing terminated aUor below land surface may require
a variance in accordance with 15A NCAC 2C 0118
e YIELD (gpm) 8 METHOD OF TEST Siaht
f DISINFECTION Type hth Amount 5 OZ
9
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thn.kness/
7 CASING Depth Diameter Weight Material
Top O Bottom 116 Ft 6 1/4 sdr 21 pvc
eB ; r 0 o
WATER ZONES (depth)
Top Bottom_ Ft
Top Bottom Ft
8 GROUT Depth Matenal Method
Top 0 Bottom 20 Ft cement pour
Top Bottom Ft
Top Bottom Ft
9 SCREEN Depth Diameter Slot Size Material
lop 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
0 /5
5 /110
110 /305
/
12 REMARKS
Size
Material
Formation Descnption
clay
sand rock
granite
FEB 0 2 2010
k.turLi 1 v 5cG, i iON
Iiiform.rtinp DT . ',3Gcy 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
12-08-09
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
Chris King
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