382454_Well Construction - GW1_20100413

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Depaitinent of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICA TION # 2080
1 WELL CONTRACTOR
Chna Klna
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#JF121509-03
OTHER ASSOCIAI ED PERMII#(if applicable)
SITE WELL ID #(if appl,cable)
3 WELL USE (Check Applicable Box) Residential Watei Supply fqf
DATE DRILLED 01-08-2010
TIME COMPLETED AM ❑ PM II
4 WELL LOCATION
CITY COUNTY Surry
Roundoeak Church Road
(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 ❑GPS C]Fopographic map
(location of well must be shown on a USGS two map andattached to
this form if not using GPS)
5 WELL OWNER
Lee Johnson
Owner Narne
Street Address
City or Town
Area coae Phone number
6 WELL DETAILS
TOTAL DEPTH 505
a
b
c
d
e
f
State Zip Code
DOES WELL REPLACE EXISTING WELLS YES ❑ NO Pi
WATER LEVEL Below Top of Casing 60 FT
(Use "+" rf Above Top of Casing)
TOP OF CASING IS 1 FT Above Land Surface*
*Top of casing teiminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C 0118
YIELD (gpm) 10 METHOD OF TEST SiIht
DISINFECTION Type j th Amount 8 OZ
3 � A
g WATER ZONES (depth)
Top 320 Bottom 321 Top Bottom
Top 460 Bottom 461 1 op Bottom____
Top Bottom Top Bottom
Thickness/
7 CASING Depth Diameter Weight Material
Top O Bottom 141 Ft 6 1/4 sdr 21 pvc
Top_ Bottom_ Ft
Top Bottom Ft
8 GROUT Depth Material Method
Top 0 Bottom 22 Ft cement pour
Top Bottom Ft
Top Bottom_____ Ft
9 SCREEN Depth Diameter Slot Size Material
TopBottom Ft in
Top Bottom Ft in
Top Bottom Ft in
10 SAND/GRAVEL PACK
Depth
Top Bottom Ft
Top_ Bottom__ Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
Size
m
in
Material
Formation D'"scnption
O /5 red clay
5 /130 sand rock
130
/ 145 blue granite
145 /165
Sand rock-
165 /505 blue granite
12 REMARKS
/1
Cr lrG az
J r 01
I DO HEREBY CERTIFY THAT 1 HIS 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
SIGNATURE F 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]
01-08-2010
Form GW-la
Rev 2/09