382453_Well Construction - GW1_20100413

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# DB101609-01
OTHER ASSOCIATED PERMIT#(rf applicable)
SITE WELL ID #(if applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply (�
DATE DRILLED 01-1 1-2010
TIME COMPLETED 4 30
AM ❑ PMIy
4 WELL LOCATION
CITY COUNTY SUrrV
Carolina Road
(Street Name Numbers, Community, Subdivision, Lot No
Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑Slope ❑Valley ❑ Flat ❑ Ridge ❑Other
" DMS OR 3x xxxxxxxxx DD
LATITUDE 36
LONGITUDE 75
" DMS OR DD
Latitude/longitude source LAPS Lei opographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5 WELL OWNER
Cindy Mchuah
Owner Name
Street Address
City or Town
Areacode Phone number
6 WELL DETAILS
a TOTAL DEPTH 265
State Zip Code
b DOES WELL REPLACE EXISTING WELL? YES LEI NO ❑
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 at/or below land surface may require
a vanance in accordance with 15A NCAC 2C 0118
e YIELD (gpm) 15 METHOD OF TEST siaht
f DISINFECTION Type hth Amount 8 OZ
g WATER ZONES (depth)
Top 120 Bottom 121 Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness)
7 CASING Depth Diameter Weight Material
Top 0 Bottom 110 Ft 6 1/4 sdr 21 pvc
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Material
Top 0 Bottom 20 Ft cement
Top Bottom Ft
Top Bottom Ft
Method
pour
9 SCREEN Depth Diameter Slot Size Material
Top Bottom Ft in m
Top Bottom Ft in in
Top Bottom Ft in in
10 SAND/GRAVEL PACK
Depth Size Material
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
Formation Descnption
0 /5 red clay
5 /100 sand rock
100 /265 blue granite
/
12 REMARKS
(.? /1� a�
+x, t'%
�Ov Srn91 /7rt
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 WELLOWNER
r\AAiA I/T,$cQ 01-11-2010
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
Chns 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