GW1-2021-05182_Well Construction - GW1_20210527

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RESIDENTIAL WELL CONSTRUCTION RECOpRD
North Carolina Department of Environment and Natural Resources-Division c Water Quality
WELL CONTRACTOR CERTIFICATION# 2669 I 210MO
1.WELL CONTRACTOR: f. DISINFECTION:Type N�Amount 90
KENNY JORDAN g. WATER ZONES(depth)'
Well Contractor(Individual Name) From gg To From-----4o,STo
DEIIVEY WRIGHT VVELL&PUMP CO., INC. From , C To From 26„To
iL
Well Contractor Company Name From nn To From 6 To
STREETADDRESS P-O_ROW 309 6.CASING: Thickness/
BOONE NC 2 M From 0 To go Ft Diameter Weight Material
Depth
�70- T7 G
City or Town State Zip Code From To Ft.
(_ --"one From To Ft.
Areaa code ode
2.WELL INFORMATION: 7.GROUT: Depth Material Method
From GTo20, Ft. BEMG z GMiW IqGW�
SITE WELL ID#(If applicable) From To Ft.ni ia hs
STATE WELL PERMIT#Qf applicable) From To Ft.
DWQ or OTHER PERMIT#(if applicable) 33S692 &SCREEN: Depth . Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply L* From To Ft. in. in.
DATE DRILLED 514=1 From To Ft. in. in.
TIME COMPLETED 0-4-00 AM❑ PM(R From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
Depth Size Material
CITY: DEEP GAP COUNTY Want= From _To Ft..
From To Ft.
LOTS 11&13R OFF SLEEPY CREEK TRAM OFF PO 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 66 CJAWSPN n
LATITUDE 3 — ^TJ�eG*1 A�GtLS minutes,seconds or 66 as GRANITE
LONGITUDE I;=*10 936 in a decimal format
— 88 Be G13€�A6 E
Latitude/longitude source: 4GPS ❑Topographic map 41 09- GRANITE
(location of well must be shown on a USGS topo map and ._ _rW405 GIREkA
attached to this form if not using GPS)
4.WELLOWNER 465 1165 r-RR01ii
OWNER'S NAME DANU F M 165 250 _ �GRANITE
A�AV 2 77 2021
Y
STREET ADDRESS I g 13 SUMMIT InEW P a U 260 260 111f
r] C£u51[R
NC 2✓3l�- enrtTn_. ..-..�tir�Tl t [Cv
i y or own State Zip o e �' ' - •- [40
ice—_jamkT@dII_
- ? eo7n —M - �= GRANITEArea code-Phone number
460 ,Ac 6RENICE
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: := I=4 92--._ . 2=4 loS-
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO k7 2 G-M-0l 165- A Mol 2,60-
I GM1 100 S=1 460
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) 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 j FT.Above Land Surface` f
Top of casing terminated attor below land surface may require _ a`
a variance in accordance with 15A NCAC 2C.0118 SIGNATURE OF CERTIF96 WELL CONTRACTOR DATE
e. YIELD(gpm): 15 METHOD OF TEST Air V=KIKIY IQRDI&Al '( i
PRINTffNAME OF PMSUNICONSTRUCTING THE WELL
II
Submit the original to the Division of Water Quality within 30 days.Attn:Information Mgt., Form GW-1 a
1617 Mail Service Center-Raleigh, NC 27699-1617 Phone No.[phone] ext 56'.j Rev.7/05
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