GW1-2022-09211_Well Construction - GW1_20220930

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RESIDENTIAL WELL CONSTRUCTION RECORD
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North Carolina Department of Environment and Natural Resources-Division of Water Quality
2669 ! 220099
WELL CONTRACTOR CERTIFICATION#.
1.WELL CONTRACTOR: k `
FCENPJY JORDAiV f. DISINFECTION:Type I F-!TH Amount 54
g. WATER ZONES(depth):
Well Contractor(Individual Name) From 110 To 115 From 212 To217
DEEVvEY 11yRIGHT WELL &FUME CO., INC. From TO From To
Well Contractor Company Name From To From To
STREET ADDRESS P.O.BOX 308 6.CASING: Thickness/
BOONS NC 2$6(7 Depth Diameter Weight Material
From 70 To_40 Ft. d 1/8 .350 PVC
City or Town State Zip Code From To Ft.
( US )264-2651 From To Ft.
Area code-Phone number
7.GROUT: Depth Material Method
2.WELLINFORMATION: From 0 To -20 FtBENTON1T - GravityFl=--
SITE WELL ID#(if applicable) From To Ft.18BAGS
STATE WELL PERMIT#(if applicable) From To Ft.
DWO or OTHER PERMIT#(if applicable) 361226 B.SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water SupplyXI From To Ft. in. in.
DATE DRILLED 813112022 From TO Ft. in. in.
TIME COMPLETED 03:00 AM ElPM)1 From To Ft. in. in.
9.SAND/GRAVEL PACK:
3.WELL LOCATION:
Depth Size Material
CITY:BANNER ELK COUNTY WATAUGA From To Ft.
LOT 88 MONTEACYLE OFF FOXFM DR OFF MONTE From _To Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) From _To Ft.
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
❑Slope ❑Valley ❑Flat ❑Ridge ❑Other From TO Formation Description
(check appropriate box) 0 40 SHALF Rncg
May be in degrees,
LATITUDE 3 36.19262N minutes,seconds or 40 110 GRANITF
LONGITUDE 81.84449W in a decimal format 110 115 BROWN SHALE
Latitude/longitude source: 91 GPS ❑Topographic map 115 212 GRANITE
(location of well must be shown on a USGS topo map and 212 217 HROVJN CHAI F
attached to this form if not using GPS) 217 365 t;RANITF
4.WELL OWNER
OWNER'S NAMETAMEiS&ROBIN LOVE .
-STREET ADDRES�n CASH-CUSTOM HOMES, 870.NC HWY 10
BOONE NC 28607
City or Town State Zip Code
(8( 29) )-773-4M S F_P 3 _
Area code-Phone number
1t3z 11'i'7Fc'i.'.'^1 t f _-t,•.J:r:.-:'. J ,.•
5.WELL DETAILS: 11.REMARKS: r
~A,:
a. TOTAL DEPTH: 365 2 GPM 110- 115 10 GPM 212-217 O✓x
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOAC]
c. WATER LEVEL Below Top of Casing: 100 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 at/or below land surface may require
a variance in accordance with 15A NCAC 2C.0118 SIGN ERTIFIED WELL CONTRACTOR DATE
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e. YIELD(gpm): 12 METHOD OF TEST Air ENNY JORD.AN
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 Rev.7/05
568.

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