GW1-2023-00479_Well Construction - GW1_20230104

RESIDENTL4L WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 2669 220098
1.WELL CONTRACTOR: f. DISINFECTION:Type HT Amount 32
KENNETH JORDAN g. WATER ZONES(depth):
Well Contractor(Individual)Name From 158 To 161
From 183 To 187
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 0 To 145 Ft. Fi 1/4 188 ('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 Material Method
From 0 To 20 Ft. BENTONIT GRAVITY
_ "SITE WELL ID#(if applicable) _ _ From To - i Ft.-26 BAGS-
WELL CONSTRUCTION PERMIT#337772 From To -Ft.
OTHER ASSOCIATED PERMIT#(if applicable)
9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply IX From To .Ft. in. in.
DATE DRILLED 12/14/2022 From To Ft. in. in.
TIME COMPLETED_0300 AM 0 PM OX From To Ft. in. in.
4.WELL LOCATION: 10.SAND/GRAVEL PACK:
CITY: ZIONVILLE COUNTY WATAUGA Depth Size Material
From To Ft.
C-43 SUNALEI PRESERVE OFF HIGH BRANCH RD From To Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Cade) From '- '-To Ft.-
TOPOGRAPHIC/LAND SETTING:
0 Slope 0 Valley 0 Flat .0 Ridge 0 Other 11.DRILLING LOG
(check appropriate box)
May be in degrees, From TO Formation Description
LATITUDE _ — 36.33440N minutes,seconds or 0 23 BLACK BROWN DIRT
LONGITUDE 81•71765W in a decimal format 23 122 rRAVFI R01 ii o RS YFI I OW CI AY MID
— — 122 158 GRANITE
Latitude/longitude source: X GPS o Topographic map 158 161 FLINT QUARTZ
(location of well must he shown on a USGS topo map and 161 183 GRANITE
attached to this form if not using GPS) 183 187 SHALE ROCK GRANITE
187 220 GRANITE
5.WELL OWNER
DANIEL&MEGAN HAYES
OWNER'S NAME
STREET ADDRESS 208 MERIDALE DR
JOHNSON CITY TN 37601
City or Town State Zip Code
(704 )- 225-7874
Area code- Phone number 12. REMARKS:
5 GPM 158-161
6.WELL DETAILS: 25 GPM 183-187
a. TOTAL DEPTH: 220
b. DOES WELL REPLACE EXISTING WELL? YES 0 NOX I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
c. WATER LEVEL Below Top of Casing: 63 FT.
15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
(Use"+"if Above Top.of Casing)
d. TOP OF CASING IS 1 FT.Above Land Surface' iU 4l 0a
*Top of casing terminated at/or below land surface may require SIGNATURE Or TIFIED;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
I
Submit the original to the Division of Water Quality 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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