GW1-2023-01178_Well Construction - GW1_20230127

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RESIDENTL4L WELL CONSTRUCTION RECORD
g, North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 2669 220112
1.WELL CONTRACTOR: f. DISINFECTION:Type_HTH Amount 120
KENNETH JORDAN g. WATER ZONES(depth):
Well Contractor(Individual)Name
From 330 To 335 _ From 635 To 642
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/
Depth Diameter Weight Material
BOONE NC 28607 From
_Q_To_80 Ft. R 118 -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. 21 BAGS
WELL CONSTRUCTION PERMIT#366967 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 1/11/2023 From To Ft. in. in.
TIME COMPLETED 0300 AMU PM UX From To .Ft. in. in.
4.WELL LOCATION: 10.SAND/GRAVEL PACK:
CITY: SUGAR GROVE COUNTY WATAUGA . Depth Size Material
From To _Ft.
OFF HWY 321 N OFF HWY 421 N OFF HWY 105 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)
May be in degrees, From To Formation Description
LATITUDE _ _ 36.24456N minutes,seconds or 0 62 BROWN SHALE
LONGITUDE 81.82604W in a decimal format 62 330 GRA tITF
330 335 PINK SLATE BROWN SHALE
Latitude/longitude source: X GPS 0 Topographic map 335 635 PINK QUARTZ GRANITE
(location of well must be shown on a USGS topo map and 635 642 SHALE ROCK PINK QUARTZ BROWN SHALE
attached to this form if not using GPS) 642 700 PINK QUARTZ GRANITE
5.WELL OWNER
OWNER'S NAME FRANK PATTERSON C/O PENNICK C _ a
STREET ADDRESS 252 POPLAR LEAF DR _.
VILAS NC 28692 AN 2
City or Town State Zip Code
82( 8 )- 773-6602 F� l jn,
Area code- Phone number 12. REMARKS:
s.WELL DETAILS: 1 GPM 330-3358 GPM 635-642
a. TOTAL DEPTH: 700
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: 100 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- /v` —
*Top of casing terminated at/or below land surface may require SIGNATUR CERTIFIED WELL CONTRACTOR DATE
a variance in accordance with 15A NCAC 2C.0118. KENNETH JORDAN
e. YIELD(gpm): 9 METHOD OF TEST AIR 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 568. Rev.3/07

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