GW1-2022-10193_Well Construction - GW1_20221111

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RESIDENTIAL WELL CONSTRUCTION RECORD
gNorth Carolina Department of Environment and Natural Resources-Division ol'iWatcr Quality
WELL CONTRACTOR CERTIFICATION# 2669 220012
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 48
KENNETH JORDAN g. WATER ZONES(depth):'
Well Contractor(Individual)Name From 117 To 121 From 170 To 176
DEWEY WRIGHT WELL&PUMP CO., INC From 190 To 196 From To
Well Contractor Company Name From To From To
STREET ADDRESS PO BOX 308 7. CASING: Thickness/
BOONE NC 28607 Depth Diameter Weight Material
From 44 Ft. 6 1/8 350 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
From 0 To 20 Ft. BENTONIT GRAVITY
SITE WELL ID#(if applicable) From To Ft. 25 BAGS
WELL CONSTRUCTION PERMIT#241277 From To__Ft.
OTHER ASSOCIATED PERMIT#(if applicable)
9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply 0 From To Ft. in. in.
DATE DRILLED 11/4/2022 From To Ft. in. in.
TIME COMPLETED 0300 AM 0 PM OX From To Ft. in.
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4.WELL LOCATION: 10.SAND/GRAVEL PACK:
CITY: TODD COUNTY WATAUGA Depth Size MatN@V i 202
From To .Ft.
3757 BIG HILL RD OFF 194 OFF 421 From To Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) From—To—'Ft
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TOPOGRAPHIC/LAND SETTING:
0 Slope o Valley D Flat 0 Ridge 0 Other 17. DRILLING LOG
(check appropriate box)
May be in degrees, From TO Formation Description
LATITUDE — — 36.29085N minutes,seconds or 0 27 RED DIRT SHALE ROCK
LONGITUDE 81.60751 W in a decimal format 27 43 SHAI E ROCK GRANITE
— — 43 117 GRANITE
Latitude/longitude source: X GPS o Topographic map 117 121 FLINT,WHITE QUARTZ
(location of well must be shown on a USGS topo map and 121 170 GRANITE
attached to this form if not using GPS) 170 176 FLINT WHITE QUARTZ
176 190 GRANITE
5.WELL OWNER 190 196 FLINT WHITE QUARTZ
OWNER'S NAME DERRICK CREEL 196 240 GRANITE
STREET ADDRESS 951 TURNER SWAMP RD
FREMONT NC 27830
City or Town State Zip Code
2( 52 )- 245-6897
Area code- Phone number 12. REMARKS:
.5 GPM 117-121
6.WELL DETAILS: 9.5 GPM 170-176
a. TOTAL DEPTH: 240 20 GPM 190-196
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO➢C 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: + FT. RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
(Use"+"if Above Top of Casing)
d. TOP OF CASING IS 1 FT.Above Land Surface* ��d ie f✓
"Top of casing terminated at/or below land surface may require SIGNATURE OF C156FIFIED WELL CONTRACTOR DATE
a variance in accordance with 15A NCAC 2C.0118. KENNETH JORDAN I'
e. YIELD(gpm): 30 METHOD OF TEST AIR PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water(duality within 30 days. Attn: 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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