GW1--03125_Well Construction - GW1_20230505

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:6 1-' ' % , RESIDENTIAL WELL CONSTRUCTION RECORD
•J (` ,e; North Carolina Department of Environment and Natural Resources-Division of Water Quality
4 -",^,`-,'.'' WELL CONTRACTOR CERTIFICATION# 2669 220053
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 64
KENNETH JORDAN g. WATER ZONES(depth):
Well Contractor(Individual)Name From 270 To 310 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/
Depth Diameter Weight Material
BOONE NC 28607 From f) To 710 Ft. 6 1/4 IRS ( Al V
City or Town State Zip Code From To Ft.
(828 )_264-2651 From To Ft.
Area code- Phone number
2.WELL INFORMATION: 8. GROUT: Depth Material Method
From 0_ _ .To.20 Ft.__BENT_ONIT_.GRAVITY . ___
SITE WELL ID#(if applicable) From To Ft. 22 BAGS
WELL CONSTRUCTION PERMIT#183498 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 4/17/2023 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: DRY HOLE COUNTY WATAUGA Depth Size Material
From To Ft.
LOT#20 OFF BOULDER CREEK DR, OFF RUSS CC 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 — 36.190491 minutes,seconds or 0 197 DIRT
LONGITUDE 81.714700 in a decimal format 197 270 GRANITE
— — 270 310 GRANITE PINK QUARTZ
Latitude/longitude source: X GPS t Topographic map 310 370 SHALE
(location of well must be shown on a USGS topo map and 370 430 GRANITE PINK QUARTZ
attached to this form if not using GPS) 430 610 GRANITE
610 660 SHALE
5.WELL OWNER
660 700 GRANITE
OWNER'S NAME DARIN LEVIN 700 740 SHALE r•7-- s 3_-
STREET ADDRESS 330 CHANTICLAIR DR 740 1005 GRANITE ��, LY r g �, i_- 1
APEX NC 27502 ,e r UL03
City or Town State Zip Code �)�1 LQ
517 480-7786 7r;::;R;:,':0 Ur.
Area code- Phone number 12. REMARKS: Itl't+�.. - D�;'.ia;.:3'�'
.25 GPM 270-310
6.WELL DETAILS:
a. TOTAL DEPTH: 1005 - _
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: 700 FT, RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
(Use"+"if Above Top of Casing) J�// �c9
d. TOP OF CASING IS 1 FT.Above Land Surface* �� - ^" v
*Topof casingterminated at/or below land surface mayrequire SIGNATUREF�TIFIED WELL CONTRACTOR DATE
9
a variance in accordance with 15A NCAC 2C.0118. KENNETH JORDAN
e. YIELD(gpm): .25 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-la
1617 Mail Service Center—Raleigh,NC 27699-1617 Phone No.[phone] ext 568. Rev.3/07

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