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HomeMy WebLinkAbout380865_Well Construction - GW1_20100202RESIDENTIAL 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 (919) 807-6300 Form GW-la Rev 2/09