GW1-2022-10708_Well Construction - GW1_20221205

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RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 2669 220125
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 56
KENNETHJORDAN g. WATER ZONES(depth),:
Well-Contractor(Individual)Name
From 52 To 60 ' 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 Depth Diameter Weight Material
From Tom_Ft. 6 1/4 188 C,'AI V
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 i Material Method
From 0 To 20 i Ft. BENTONIT GRAVITY _
-- -SITE-WELL ID#(if applicable) — -- From To l Ft. 23 BAGS
WELL CONSTRUCTION PERMIT#852767 From To Ft.
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 11/17/2022 From To Ft. in. in.
TIME COMPLETED 0300 AMU PM UX From To Ft. in. in.
4.WELL LOCATION: 10.SAND/GRAVEL PACK:
�,
CITY: BANNER ELK COUNTY AVERY Depth Size Material,
From To Ft. �;'LOT S-21 OFF EAGLE ROCK PATH OFF EAGLES C From To FtL
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) From TO Ft.
TOPOGRAPHIC/LAND SETTING:
U Slope 0 Valley 0 Flat 0 Ridge 0 Other tn,;�;ar son Ur?r: Ur(check appropriate box) 11. DRILLING LOG raa�at�/u
LATITUDE 36.12758 Maybe in degrees, From TO Formation D'escrlptlon
— — minutes,seconds or 0 8 BLACK DIRT
LONGITUDE 81.44191 in a decimal format 8 52 GRANITE
— — 52 60 FLINT WHITE QUARTZ
Latitude/longitude source: X GPS u Topographic map 60 300 GRANITE WHITE QUARTZ
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS) I I
5.WELL OWNER I
OWNER'S NAME DWIGHT JACOBS C/O SKYHOUSE CI I
STREET ADDRESS 2874 TYNECASTLE HWY
BANNER ELK NC 28604
City or Town State Zip Code
(828 )_ 898-3717
Area code- Phone number 12. REMARKS:
12 GPM 52-60
6.WELL DETAILS:
a. TOTAL DEPTH: 300
b. DOES WELL REPLACE EXISTING WELL? YES 0 NOX I W DO HEREBY CERTIFY THAT THIS ELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
c. WATER LEVEL Below Top of Casing: 21 FT. RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
(Use"+"if Above Top of Casing) yyp
d. TOP OF CASING IS 1 FT.Above Land Surface`
"Top of casing terminated attor below land surface may require SIGNATURKOF CERTIFIER WELL CONTRACTOR DATE
a variance in accordance with 15A NCAC 2C.0118. KENNETH JORDAN
e. YIELD(gpm): 12 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. Attn:Information Mgt., W-1a
1617 Mail Service Center—Raleigh,NC 27699-1617 Phone No.[phone] ext 568. Form G I Rev.

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