GW1-2021-06936_Well Construction - GW1_20210505

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RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 2669 210027
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 38
KENNY JORDAN g. WATER ZONES(depth):
Well Contractor(Individual Name) From 105 To From 130To
DEWEY WRIGHT WELL PUMP CO., INC. From 175 To From To
Well Contractor Company Name From To From To
STREET ADDRESS P.O.BOX 308 6.CASING: Thickness/
BOONE NC 286Qq Depth Diameter Weight Material
From 0 To_K,Ft 6118 .350 PVC
City or Town State Zip Code From To Ft:
( 828 )-264-2651 From To Ft.
Area code-Phone number
2.WELL INFORMATION: 7.GROUT: Depth Material Method
From 0 To 20 Ft! BMUONIT Gravity Flow
SITE WELL ID#(if applicable)---- - --- ---- -From To ft!21 BAGS
STATE WELL PERMIT#(if applicable) From To Ft.
DWQ or OTHER PERMIT#(if applicable) 335001 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply LZ From To Ft. in. in.
DATE DRILLED 4/23=1 From To Ft. in. in.
TIME COMPLETED 03:00 AM❑ PM From To Ft. in. in.
3.WELL LOCATION: 9.SAND/GRAVEL PACK:
Depth � Size Material
CITY: WEST]SFFtERSON COUNTY ASM From To Ft.
OFF NE=KNOB RD OFF 221 OFF HWY 421 From _To Ft.
From _To Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
❑Slope ❑Valley ❑Flat ❑Ridge ❑Other From To Formation Description
(check appropriate box) 0 43 CLAY/SAND
Maybe in degrees,
LATITUDE s N3M.109 minutes,seconds or 43 52 LIMESTONE
LONGITUDE 1J 081+X64$ in a decimal format 52 105 GRANITE
Latitude/longitude source: q(GPS ❑Topographic map 105 105 CREMrF
(location of well must be shown on a USGS topo map and 105 130 GRANITF
attached to this form if not using GPS) 130 130 CRFMCE
4.WELL OWNER 130 175 GRANITE
OWNER'S NAME ANDREA SON 175 175 CFtFv[CF
STREET ADDRESS PO BOX 609* 175.._ 225. -. GRANITE
WEST JSFFERSON NC 2$644
City or Town State Zip Code 1 V y--
33 - 607-4787
Area code-Phone number MAY
5 a. TOTALTDEPTH: 11.REMARKS: I11fOf111atbn PCmeasing U Qjjon
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b. DOES WELL REPLACE EXISTING WELL? YES❑ NO k7 'Acam_17S-
c. WATER LEVEL Below Top of Casing: 45 FT. I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
(Use"+"if Above Top of Casing) 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OFTHIS
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 require 4�
a variance in accordance with 15A NCAC 2C.0118 SIGNA OF CERTIFIED WELL CONTRACTOR DATE
I
e. YIELD(gpm): 6 METHOD OF TEST Air
PRINT M 8PRS ' 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,INC 27699-1617 Phone No.[phone] ext 566. Rev.7/05
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