GW1-2021-06884_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 i 210%4
1.WELL CONTRACTOR: t
f. DISINFECTION:Type HTH Amount 43
KENNY JORDAN g. WATER ZONES(depth):
Well Contractor(Individual Name) From 84 To 87 From 1 To 143
DE%VEY*.ARIGHT VVELL &PUMP CO., INC. From iss To irt7 From oft aTo 209
Well Contractor Company Name From To From To
STREET ADDRESS P.O.BOX 308 6.CASING: Thickness/
Depth Diameter Weight Material
$OOHS NC - 607 From 0 To 47 Ft. 61is, 350 gV(1
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. 13ENP'ONTT Gravimzylaw
SITE-WELL ID#of applicable)__ —_ _ From__ ._To ___Et,_27-BAGS
STATE WELL PERMIT#(if applicable) From To Ft.
DWO or OTHER PERMIT#(if applicable) 328637 8.SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply ix From To Ft. in. in.
DATE DRILLED 4/2&=1 From To Ft. -in. in.
TIME COMPLETED 03:00 AM❑ PM ig From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
Depth Size Material
CITY: LANMNG COUNTY ASHE From To Ft.
OFF S RIVER HILLS RD OFF RIVER HILLS OFF 5IL 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) a 24 RED CLAY
May be in degrees,
LATITUDE 3 36.493213 minutes,seconds or 24_- 84 GRANITE
LONGITUDE -81.431799 in a decimal format 84 87 VOID
Latitude/longitude source: q(GPS ❑Topographic map 87 14D GRANITE
(location of well must be shown on a USGS topo map and 140 143 Vdln
attached to this form if not using GPS) 143 185 GRANITE
4.WELL OWNER 185 187 VOID
OWNER'S NAME EDD&LYNNE GARBRICK 197 205 GRANITE
STREET ADDRESS PO BOX 21161 . 205 209 _ VOID.
BRADEI41ON FL 34204 209 245 GRANITE
City or Town State Zip Code
(( 941) )- 840-2299 � o,
Area code-Phone number �� g
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5.WELL DETAILS: 11.REMARKS: se6
a. TOTAL DEPTH: 245 2 GPM 94-97 1 GPM 140- 143
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO 2 GPM 195-187 3 GPM 205-209��
c. WATER LEVEL Below Top of Casing: 40 Fr. 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 OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land Surface* �� a
*Top of casing terminated at/or below land surface may require B"
a variance in accordance with 15A NCAC 2C.0118 SIGN F CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): 8 METHOD OF TEST Air KENNY JORDAN
PRINTED NAME OF PERSON 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
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