382452_Well Construction - GW1_20100413

RESIDENTIAL WELL CONS [RUCTION RECORD
Nor th Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CER1►FICATION # 2080
1 WELL CONTRACTOR
Chris Kina
Well Contractor (Individual) Name
Raymond Brawn 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 8 GROUT Depth Material Method
2 WELL INFORMATION Top O ___ Bottom 20Ft cement pour
WELL CONSTRUCTION PERMIT# JF121509-04 Top Bottom Ft
g WATER ZONES (depth)
Top 170 Bottorn 171 Top Bottom
Top 470 Bottom 471 TopBottom
Top Bottorn Top 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
OTHER ASSOCIATED PERMIT#0 applicable) Top Bottom Ft
SITF WELL ID #(if applicable) 9 SCREEN Depth Diameter Slot Size Material
3 WELL USE (Check Applicable Box) Residential Water Supply V Top Bottom Ft
DATE DRILLED 01-06-2010 Top Bottom Ft ur in
Top Bottom Ft
TIME COMPLETED AM CI PM El
10 SAND/GRAVEL PACK
4 WELL LOCATION Depth Size Material
CITY COUNTY SUrry Top_____ Bottorn Ft
Roundoeak Church Road Top Bottom Ft
(Street Name, Numbers, Community Subdivision Lot No Parcel, Z!p Code) Top Bottom Ft
TOPOGRAPHIC / LAND SETTING (check aoproonate box)
E Slope [Valley ❑Flat ❑Ridge D Other
LATITUDE 36 0 ' DMS OR 3x XXXXXXXXX DD
LONGI FUDE 75 " DMS OR DD — /
11 DRILLING LOG
Top Bottom
Latitude/longitude source DGPS [Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS) 5 / 115 sand rock
Formation Descnption
0 /5 red clay
5 WELL OWNER 115 /505 blue granite
Lee Johnson
Owner Name
Street Address
City or Town
(— )
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 505
State Zip Code
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO gr
c WATER LEVEL Below Top of Casing 60 FT
(Use'+" if Above Top of Casing)
d TOP OF CASING IS 1 FT Above Land Surface*
'Top of casing terminated at/or 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 10 OZ
12 REMARKS
art
144
< 010
it
-�r 9tsfp,Y
I DO HEREBY CERTIFY 1 HAT 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
01-06-2010
SIGNATURE OF CERTIFIEI WELL CONTRACTOR DATE
Chris King
PRINTED NAME OF PERSON CONSTRUCTING I HE 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