GW1-2021-00549_Well Construction - GW1_20210219

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RESIDENTIAL WELL CONSTRUCTION RECORD
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North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 266g
1.WELL CONTRACTOR:
KENNY JORDAN f. DISINFECTION:Type iHTH Amount 1?�t g. WATER ZONES(depth):'
Well Contractor(Individual Name) From 280 To From 620To
DEWEY WRIGHT WELL&PUMP CO., INC. From 760 To From - To
Well Contractor Company Name From To From To
STREET ADDRESS p O.BOX 308 6.CASING: Thickness/
BOONE NC 2WO Depth Diameter Weight Material
From 0 To 40 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 21 Ft. EMONIT Gravity Flow
SITE WELLID#(if applicable) -_ : _ _From- __To _. Ft._14BAGS__
STATE WELL PERMIT#(if applicable) From To Ft.
DWO or OTHER PERMIT#(f applicable) 290324 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply Lx From To Ft. in. in.
DATE DRILLED 2/9/2021 From To Ft. in. in.
TIME COMPLETED 03:00 AM❑ PM in From To Ft. in. in.
9.SAND/GRAVEL PACK:
3.WELL LOCATION:
Depth Size Material
CITY: BLAWINGROCK COUNTY WpTa= From To Ft.
OFF SHORE DR OFF MACK HJkLW 'ON RD OFF HW 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) May be in degrees, 0 14 SHELL ROCKfGRANITI
LATITUDE 3 minutes,seconds or 14 2$0 GRANITE
LONGITUDE in a decimal format 280 280 CREVICE
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Latitude/longitude source: OXGPS ❑Topographic map 280 620 GRANITFJUMESTONE
(location of well must be shown on a USGS topo map and 620 620 CREVICE N c
attached to this form if not using GPS) 620 760 GRANITE _� c W,o
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4.WELL OWNER 760 760 CREVICE t o i a e
CO
OWNER'S NAME JONATHAN SHORE 760 805 GRANITE
STREET ADDRESS%CASH CUSTOM HOMES, 870 NC HWY 10 Sb y
BOONE NC 286M LL_ o
City or Town State Zip Code
( (8?.8') )- 297-1130
Area code-Phone number
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 805 0.25 GPM 280- 0.25 GPM 620-
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOJO 0.5 GPM 760-
j
c. WATER LEVEL Below Top Of Casing: 180 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 OF THIS
RECORD HAS BEEN ROVIDED 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
a variance in accordance with 15A NCAC 2C.0118 SIGNAT ERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): 1 METHOD OF TEST Air KENNY JORDAN i
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days.Attn: Information Mgt., Form GW-1 a
1617 Mail Service Center-Raleigh,INC 27699-1617 Phone No. [phone] ext 568.! Rev.7/05
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