GW1-2021-01634_Well Construction - GW1_20210329

`STA1Fo
3 RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
�a ® WELL CONTRACTOR CERTIFICATION# 2669 200M
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 76
KENNY JORDAN g. WATER ZONES(depth):
Well Contractor(Individual Name) From 240 To 240 From 35OTo 353
OeA'EY MIGHT III&PUMP CO., INC. From To From To
Well Contractor Company Name From To From TO
STREET ADDRESS P.O.BOX 308 S.CASING: Thickness/
BOONE NC 2W Depth Diameter Weight Material
Fromm To—AL, Ft. 61/8 .350 PVC
City or Town State Zip Code From To FL
( W8 )-264-2651 From To Ft.
Area code-Phone number
2WELL INFORMATION: 7.GROUT. Depth Material Method
From_0 To_20_ Ft. BENTONIT GrWityFlow
SITE WELL ID#(n applicable) From To Ft. 27 BAGS
STATE WELL PERMIT#(a applicable) From To Ft.
DWG or OTHER PERMIT A(dapplleable) DIM S.SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply Lz From To Ft.—In. in.
DATE DRILLED 3/13/2021 From To Ft. in. in.
TIME COMPLETED 03:00 AM❑ PM rA FromTo Ft. in. in.
9.SAND/GRAVEL PACK:
3.WELL LOCATION:
Depth Size Material
CITY: WBSr JEFFEIWN COUNTY ASHE From To Ft.
443 HARDWOOD HILL.OFF GUC3.RD OFF W RE From _To Ft.
From TO Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
❑Slope 0 Valley 0 Flat 0 Ridge 0 Other From TO Formation Description
(check appropriate box) 0 25 CLAY/SAND
Maybe in degrees,
LATITUDE 114 minutes,seconds or 25 240 GRANITE
LONGITUDE W081*M.050 in a decimal fomtat 240 240 CREVICE
lantude/longitudesource: CI(GPS ❑Topographicmap 2d0 350 GRANITE
(location of well must be shown on a USGS topo map and 3W 393 volt
attached to this form if not using GPS) 353 A25 GRANLTF
4.WELL OWNER
OWNER'S NAME PAUL T.OWR -d
ful
STREET ADDRESS 201 RILi.INGRATH TURN N
CARY NC 77510 s s A I1 2 8
City or Town State Zip Code �P
( ing
(919) )- 614-7245 ,_r.,r"a=Prcces n
Area code-Phone number �`T'� p`"� WR 9 101
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 425 0 S GPM 240-?AO 4 S GPM 150_ 151
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO 0%
Bing: 40 FT. I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
c. WATER LEVEL Below Top of Casing:
(Use if Above Tops Casing) 1SA NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land Surface'
Top of casing terminated at/or below land surface may requiretz
a variance In accordance with 15A NCAC 2C.0118 SZaNA CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): S METHOD OF TEST -A:.
PRINT M S CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt., Form GW-1a
1617 Mail Service Center- Raleigh, NC 27699-1617 Phone No. [phone] ext 568. Rev.7/05