380889_Well Construction - GW1_20100202

RESIDENTIAL WLLL CONSTRUCTION RECORD
North Carolina Dept Imam of hnvuonment and Natural Resouices- Division of Water Quality
WELL CON l [(ACTOR CERTIFICATION # 2080
1 WELL CONTRACTOR
Chris Kind
Well Contractor (Individual) Name
Raymond Brown Weil Company Inc
Well Contractor Company Name
1109 N Main Street
Street Address
Danbury
City or Town
( 336 ) 593-8239
Area code Phone number
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT# SAS120409-01
NC 27016
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply fi
DATE DRILLED 12-10-09
TIME COMPLETED 3 00 AM ❑ PM CAS
4 WELL LOCATION
CITY COUNTY Surry
149 Howell Road
(Street Name Numoers, Community, Subdivi ion, Lot No Parcel Zip Code)
TOPOGRAPhtIC / LAND SETTING (check appropriate box)
❑Slope ❑Valley ❑Flat ❑ Ridge ❑Other
LATITUDE 36 ' " DMS OR 3x xxxxxxxxx DD
LONGITUDE 75 °_-'._ " DMS OR DD
Latitude/longitude source LJ PS ❑topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5 WELL OWNER
Ed Llrllev
Owner Name
Street Address
City or Town
( )
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 825
State Zip Code
b DOES WELL REPLACE EXISTING WELL? YES 21 NO 0
c WATER LEVEL Below Top of Casing 120 FT
(Use '+" if Above Top of Casing)
d 1 OP OF CASING IS 1 FT Above Land Surface'
*Top of casing terminated at/or below land surface may requite
a variance in accordance with 15A NCAC 2C 0118
e YIELD (gpm) 1/2 METHOD OF TEST SIaht
f DISINFECTION Type hth Amount 100 OZ
g WATER ZONES (depth)
Top 130 Bottom 131 lop_ Bottom
Top Bottom Top Bottom
Top Bottom rop Bottom
Thickness/
7 CASING Depth Diameter Weight Material
Top 0 Bottom 120 Ft 6 1/4 sdr 21 pvc
Top Bottom Ft
Top
Bottom Ft
8 GROUT Depth Material
Top 0 Bottom 20 _ Ft cement pour
lop Bottom Ft
Top Bottom Ft
Methoa
9 SCREEN Depth Diameter Slot Size Material
Top Bottom Ft in in
Top Bottom Ft in m
Top Bottom Ft in in
10 SAND/GRAVEL PACK
Depth Size Material
Top Bottom_ Ft
Top Bottom Ft
Top BottomFt
11 DRILLING LOG
fop Bottom
0 /5
5 /115
115 /825
12 REMARKS
Formation Descnption
red clay
sand rock
blue granite
FEB 0 2 1010
WATEr, LtUi\Li i Y SECTION
Inform ,i-
I DO HEREBY CERTIFY THAT THIS WELL WAS CONS VRUCTED IN
ACCORDANCE WITH 15A NCAC 2C WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER
SIGNATURE OF CERTIFIED WC L CONTRACTOR DATE
12-10-09
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