GW1-2022-09130_Well Construction - GW1_20220930

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RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
2669 t 220102
WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 87
KENNY JORDAN
g. WATER ZONES(depth):
Well Contractor(Individual Name) From 110 To 113 From 210 To213
D VVtY VVKIGH 1 VV LL &PUMP CO., NC. From d$n To 4H From To
Well Contractor Company Name From v TO From To
STREET ADDRESS P.0.BOX 308 6.CASING: Thickness/
130ONE NC 2$607 Depth Diameter Weight Material
From 0 To 41 Ft. 6 U'8 .350 PVC
City or Town State Zip Code From To Ft.
( 8M )264-2651 From To Ft.
Area code-Phone number
7.GROUT: Depth - Material Method
2.WELL INFORMATION:
From._ 0.-To 20--Ft$E 4TON11T SITE WELL ID#(if applicable) r From To Ft.18 BAGS
STATE WELL PERMIT#(if applicable) From To Ft.
DWO or OTHER PERMIT#(rt applicable) 10531 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply ) From To Ft. in. in.
DATE DRILLED 9/9/2022 From To Ft. in. in.
TIME COMPLETED 03:00 AM❑ PM) From To Ft._in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
Depth Size Material
CITY:13ANNMELK COUNTY AVERY From To Ft.
970 OLD BEECH MT'N RD OFF SAM Rt 7 ER OFF 194 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) 0 10 HRf�WN nIRT
May be in degrees,
LATITUDE 3 36.19$91N minutes,seconds or in 110 GRAYROCK/ELINT
in a decimal format
LONGITUDE 81.92495W till 115 14HAI F RnrK
Latitude/longitude source: 14 GPS ❑Topographic map 115 2In PINK 01IART71F1 INT
(location of well must be shown on a USGS topo map and 210 215 BROWN SHAI F
attached to this form if not using GPS) 215 480 GRANITElPINK SLATE
4.WELL OWNER 480 486 GREEN qI AT 1 RANI'
OWNER'S NAM9MAN'K&CAROLYN FAIST 486 520 ):RAY rRANITF
STREET ADDRESVa QUALITY BUILDERS. PO BOX 397-
BANNER EL.K NC 28604 RE <_-E 4 v
City or Town State Zip Code
(( $287 )-387-7116 SEP3
Area code-Phone number
5.WELL DETAILS: 11.REMARKS: '►31?'1c�2.ItOC#
a. TOTAL DEPTH: 520 1 (TMA 1 l 0- ]i s I M.4 210-215
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOAE] 2S(And 480-486
c. WATER LEVEL Below Top of Casing: 102 FT. I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
(Use"+"if Above Top of Casing) 1 5A 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 at/or below land surface may require —6P
a variance in accordance with 15A NCAC 2C.0118 SIGNATU RTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): 27 METHOD OF TEST Air If
v
PRINT AME N 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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