GW1--03998_Well Construction - GW1_20230612

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' RESIDENTML WELL CONSTRUCTION RECORD
,1, Q, North Carolina Department of Environment and Natural Resources-Division of Water Quality
'4,.11 RKw '�" l
':'" -,,,"''' WELL CONTRACTOR CERTIFICATION# 3867 220182
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 49
Udall Main g. WATER ZONES(depth):
Well Contractor(Individual)Name From 170 To 180 From_27.0 To 271
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 (1, To 1(l5 Ft. 6 1/8 350 PVC
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
SITE WELL ID#(ifapplicable) From 0 To 23 Ft. BENTONIT GRAVITY
- - - --- - - From - To rFt.-32 BAGS-- - --- ---- ——�---
WELL CONSTRUCTION PERMIT# 115832 From To Ft.
OTHER ASSOCIATED PERMIT#(if applicable)
9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply[I From To_ Ft. in. in.
DATE DRILLED 6/7/2023 From To Ft. in. in.
TIME COMPLETED MOO AM 0 PM OX From To Ft. in. in.
4.WELL LOCATION: 10.SAND/GRAVEL PACK:
CITY: LINVILLE COUNTY AVERY Depth Size Material
From To Ft.
LOT 38B EDELWEISS CIR OFF BAUMDORF OFF A From To ' Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) From To Ft.
TOPOGRAPHIC/LAND SETTING:
X Slope 0 Valley 0 Flat 0 Ridge II Other
(check appropriate box) 11. DRILLING LOG
May be in degrees, From To Formation Description
LATITUDE —— 36.06900N minutes,seconds or 0 89 DIRT
LONGITUDE 81.89073W in a decimal format 89 170 GRANITE
— — 170 180 QUARTZ
Latitude/longitude source: )4 GPS o Topographic map 180 230 GRANITE •
(location of well must be shown on a USGS topo map and 230 270 SHALE
attached to this form if not using GPS) 270 271 VOID
271 305 GRANITE
5.WELL OWNER _
OWNER'S NAME"JASON BLAIR - 11r E i
STREET ADDRESS 3497 MELICA DR
TERRELL NC 28682 - SUN 1
City or Town_ State Zip Code .
(704 . )_ 962-9800 • Informatin Prc.,. ,..ri Urit
• Dt.10/;30G
Area code- Phone number 12. REMARKS:
5 GPM 170-180
6.WELL DETAILS: 15 GPM 270-271
a. TOTAL DEPTH: 305
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO X 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: 60 FT. RECO-`HAS BEEN PROV-:�E■TO THE WELL 9y/NER.
(Use"+"if Above Top of Casing) / // tI
d. TOP OF CASING IS 1 FT.Above,Land Surface* % ` 49/843
*Top of casing terminated at/or below land surface may require SIGNATURE OF CERTIFIED WELL ONTRACTOR DATE
a variance in accordance with 15A NCAC.2C.0118. RANDALL MAIN
e. YIELD(gpm): 20 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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