GW1-2022-09949_Well Construction - GW1_20221031

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RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 2669 220035
1:WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 72
KENNETHJORDAN g. WATER ZONES(depth):
Well Contractor(Individual)Name From 494 To 502 From To
DEWEY WRIGHT WELL&PUMP CO., INC From To From To
Well Contractor Company Name From To From To
STREET ADDRESS PO BOX 308 7. CASING: Thickness/
BOONE NC 28607 From Depth Diameter Weight Material
�_To_4D t. R 1/8 31in PVC
City or Town State Zip Code From To Ft.
8( 28 -264-2651 From To Ft.
Area code- Phone number
2.WELL INFORMATION: 8. GROUT: Depth Material Method
SITE WELL ID#(iifapplicable) From O To 20 Ft. BENTONIT GRAVITY
From To Ft. 17 BAGS
WELL CONSTRUCTION PERMIT#184621 From To FV
OTHER ASSOCIATED PERMIT#(if applicable)
9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply X From To Ft. in. in.
DATE DRILLED 10/22/2022 From To Ft. in. in.
TIME COMPLETED 0300 AM PMOX From To Ft. in. in.
4.WELL LOCATION: 10.SAND/GRAVEL PACK: "
CITY: BOONE COUNTY WATAUGA Depth Size Material
From To Ft.
OFF SHOOTING STAR TRAIL OFF FIRETOWER OF From To Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) From—TO—Ft.
TOPOGRAPHIC/LAND SETTING:
0 Slope 0 Valley 0 Flat 0 Ridge 0 Other 11.DRILLING LOG
(check appropriate box)
LATITUDE 36.23469N May be in degrees, From TO Formation Description
—— minutes,seconds or 0 18 BROWN DIRT SHALE ROCK
LONGITUDE 81.70112W in a decimal format 18 494 r;RANITF WHITE 011ART7
— — 494 502 SHALE IROCK FLINT
Latitude/longitude source: X GPS o Topographic map 502 515 CREVICE ROCK
(location of well must be shown on a USGS topo map and 515 620 GRANITE WHITE QUARTZ
attached to this form if not using GPS)
5.WELL OWNER
OWNER'S NAME KYLE NOWAK - -; ^r,
r
STREET ADDRESS 4662 BRIDLE PATH LN
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DUBLIN OH 43017II?�
City or Town State Zip Code
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33( 0 I- 936-3705 •:
Area code- Phone number 12_ REMARKS-
15 GPM 494-502
6.WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES 0 NOX I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C.WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
c. WATER LEVEL Below Top of Casing: 260 FT. RECORD HAS BEENWIDEDOELL OWNER.
(Use"+"if Above Top of Casing)
d. TOP OF CASING IS 1 FT.Above Land Surface* /D
"Top of casing terminated at/or below land surface may require SIGNATUR ERTIFIED WELL CONTRACTOR DATE
a variance in accordance with 15A NCAC 2C.0118.
KENNETHJORDAN
e. YIELD(gpm): 15 METHOD OF TEST AIR PRINTED NAME OF PERSON CONSTRUCTING THE WELL
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Submit the original to the Division of Water Quality within 30 days. At Information Mgt, Form GW-1a
1617 Mail Service Center—Raleigh,NC 27699-1617 Phone No.[phone] ext 568. Rev.3/07
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