GW1-2021-02431_Well Construction - GW1_20210527

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RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 2669 E 190246
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1.WELL CONTRACTOR:
KENNY JORDAN f. DISINFECTION:Type HTH Amount ?S=•-
g. WATER ZONES(depth):
Well Contractor(Individual Name) From 137 To 139 From 403To 4114
UEWEY V1R iGH I WELL!Sc PUMP CO., INC. From To . From To
Well Contractor Company Name From To From To
STREET ADDRESS P.O.BOX 308 6.CASING: Thickness/
Depth " Diameter Weight Material
BOONE NC 28607 - From 0 To_105 Ft. 6114 _fag GAIV
City or Town State Zip Code From To Ft.
( $7R - From To Ft.
Area codd e- one number 7.GROUT: Depth Material Method
2.WELL INFORMATION:
From 0 To_20 Ft.pa=4= �a^:t;LF1a+Fr
SITE WELL ID#(if applicable) From To - jfznam
STATE WELL PERMIT#(if applicable) From To Ft.
DWO or OTHER PERMIT#(f applicable) 761650 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply LA From To Ft: in. in.
DATE DRILLED 517l2421 From To Ft. in. in.
TIME COMPLETED 03:00 AM❑ PM N From To Ft. in. in.
9.SAND/GRAVEL PACK:
3.WELL LOCATION:
Depth Size Material
CITY: BANNEREIX COUNTY AVERY From To Ft.
LOT ES-9 OFF EAGLE SPRING TRAM,OFF EAGLE C 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, n go tun tntut rLront n n!
LATITUDE 3 � g�� minutes,seconds or go 1186 _ GRAY GRANITE
in a decimal format
LONGITUDE cvn4i+ce cis �,� BLUE
GRANITE
Latitude/longitude source: G*GPS ❑Topographic map 1137 ram CREVICE
(location of well must be shown on a USGS topo map and i� ..
attached to this form if not using GPS)
403 .-40 — ISREMICE
-
4.WELL OWNER404 425 GRAY GRANITE
OWNER'S NAME E Te
STREET ADDRESS° -_
Rom.,�''"°E!a/E D
Ay
or own State Zip Coe 0�...
( 9( I M 1- 544016R MAY G�CU
Area code Phone number
5.WELL DETAILS: 11.REMARKS: inforr-3a on Processing Unit
a. TOTAL DEPTH: QO I G-M44 137 139- 1]rM.4 AWB&don
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO il
c. WATER LEVEL Below Top of Casing:AO 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 1 FT.Above Land Surface*
*Top of casing terminated abor below land surface may require �L -7-
a variance in accordance with 15A NCAC 2C.0118 SIGNATURE-OF CERTIFIED WELL CONTRACTOR DATE
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e. YIELD(gpm): 12 METHOD OF TEST �a PRINT ; 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,NC 27699-1617 Phone No.[phone] ext 566. Rev.7/05
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