GW1-2021-01462_Well Construction - GW1_20210329

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RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
26LV 20DW
WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: I. DISINFECTION:Type HTH Amount 69
KENNY JORDAN g. WATER ZONES(depth):
Well Contractor(Individual Name) From 120 To 124 From 240TO 240
DEWEY WRIGHT WELL&PUMP CO., INC. From 320 To 320 From To
Well Contractor Company Name From To From To
STREET ADDRESS P.O.BOX 308 6.CASING: Thickness/
BOONS NC 28607 Depth Diameter Weight Material
From 0 To 47 Ft. 6114 .188 GALV
City or Town State Zip Code From To Ft.
( U8 )-264-2651 From To Ft.
Area code-Phone number
2.WELL INFORMATION: 7.G From Depth Material Method
From 0 To 20 Ft. BSNTONTf GravttV Flow
SITE WELL ID#(napplicable) From To Ft. 25
STATE WELL PERMIT#ta applicable) From To Ft.
DWO or OTHER PERMIT#(napplicable) 186163 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply L3( From To Ft. in. in.
DATE DRILLED 3/1From To Ft. in. In.
TIME COMPLETED 03:00 AM❑ PM UI From To Ft._In. _in.
9.SAND/GRAVEL PACK:
3.WELL LOCATION:
Depth Size Material
CITY: BOONE COUNTY Wks From To Ft.
LOTS 8&9 OFF NORTH CAMP RD OFF ROWS KM T 4 From _T Ft.
From _ToO Ft—
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
❑Slope I]Valley O Flat ❑Ridge O Other From TO Formation Description
(check appropriate box) 0 27 SAND/CLAY
May he indegrees,
LATITUDE 3 N-1.069 minutes,seconds or 27 120 GRANITE
LONGITUDE W081*41356 ina decimal format 120 124 Mal
Latitudellongitude source: EXGPS ❑Topographic map 124 2,110 GRANITE
(location of well must be shown on a USGS topo map and 2I0 2A( CREVICE
attached to this form If not using GPS) S,,I0 320 GRANITE
4.WELL OWNER 32n VA CREVICE
OWNER'S NAME ROY T WANS 32n IfYI —GRANITE
STREET ADDRESS6510 CHRMTOPH R POINT Fin W-. - 7
TACKSOI 111 171. 37217
City or Town State Zip Code MAR 9. 9 702
C9m 1- 910-9190
Area code-Phone number i It
5.WELL DETAILS: 11.REMARKS: s;��.
a. TOTAL DEPTH: 400 A GIPLI 120_124 2 CTpA240-240
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO 2 GEM 120_120
c. WATER LEVEL Below Top of Casing: 60 FT I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
(Use"+"if Above Top of Casing) 1M 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 atlor below land surface may require 3— —41
a variance in accordance with 15A NCAC 2C.0118 SI CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): 10 METHOD OF TEST Air
PRIWOMAWME RPMRSN 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