GW1-2022-08806_Well Construction - GW1_20220909

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RESIDENTIAL WELL CONSTRUCTION RECORD
o North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 2669 i 2200M
1.WELL CONTRACTOR: f. DISINFECTION:Type—:HTH Amount 48
KENNY JORDA.N g. WATER ZONES(depth):
Well Contractor(Individual Name) From 115 To 120 From 210 To215
DEtiMtt'f PUMP CO., iNC:. From To From To
Well Contractor Company Name From To From To
STREET ADDRESS P.O.BOX 308 6.CASING: Thickness/
BOONE NC 286d7 Depth Diameter Weight Material
From 0 To 3r1 Ft. 6119 350 PV(7
City or Town State Zip Code From To Ft.
( $2$ )264-2651 From To Ft.
Area code-Phone number
2.WELL INFORMATION: 7.GROUT: Depth Material Method
From 0 To�0 FtBENTONTT Gravity Flow
— —SITE-WEL-L-ID-#(if-applicable) -- _._ _ _ _�---_ _. From-- To--- --Ft'7-]Rdhzr ----—
STATE WELL PERMIT#(if applicable) From To Ft.
DWQ or OTHER PERMIT#(if applicable) 363233 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply%) From To Ft. in. in.
DATE DRILLED R/2212022 From To Ft. in. in.
TIME COMPLETED 03:00 AM❑ PM}❑ From To Ft. in. in.
9.SAND/GRAVEL PACK:
3.WELL LOCATION:
Depth Size Material
CITY..BANNER ELx COUNTY WATAUGA From To .Ft.
LOT 70 MONTEAGLE OFF FOXFIRE OFF SHAWNEE 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 ToI Formation Description
(check appropriate box) May be in degrees, 0 37 BLACK DIRT/SHALEIR
LATITUDE 3 minutes,seconds or 37 115 LIMESTONE/GRANITE
LONGITUDE in a decimal format 115 120 BROWN SHA.LEIGRAN
Latitude/longitude source: Ja GPS ❑Topographic map 19ft 21f1 I IMF$TrINFMRANITE
(location of well must be shown on a USGS topo map and 21n 215 BRnwfll cN A I F4 IIMFc
attached to this form if not using GPS) 915 305I IAAFCTffflIFlGRo(�fJTF
4.WELL OWNER
i
OWNER'S NAMErMiLk.SUSAN j ATSIOS
STREET ADDRESS'a MOUNTAIN.CONSTRUCTION, PQ BOX 11
BOONE NC 2Sd07 _
City or Town State Zip Code SEP Q 3 2022
(= )-963-8090
Area code-Phone number nil
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 305 4 CTPM 115- 12.0 R GPM 210-215
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOA❑
c. WATER LEVEL Below Top of Casing: 65 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 I FT.Above Land Surface* i
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C.0118 SIGN OF CERTIFIED WELL CONTRACTOR DATE
is
e. YIELD(gpm): 12 METHOD OF TEST Air KENNY JoRDAIV
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, NC 27699-1617 Phone No.[phone] ext 568. Rev.7/05
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