GW1--06667_Well Construction - GW1_20231006

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,74I `` 1 ESIDENTL4L'WELL CONSTRUCTION RECORD
. * North Carolina Department of Environment and Natural Resources-Division of Water Quality _
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M1•"`:,,n,,•e_' WELL CONTRACTOR CERTIFICATION# 3867 230026
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1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 40
RANDALL MAIN t '
g. WATER ZONES(depth):,
Well Contractor(Individual)Name From 90 To 91 From 160 To 161
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/
BOONS NC 28607 Depth Diameter Weight Material
From 0 To 70 Ft.6 1/4 188 GAI V
City or Town State ' Zip Code From To Ft.
(828 )-264-.2651 From ,To Ft.
Area code- Phone number
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2.WELL INFORMATION: 8. GROUT: Depth Material Method
SITE WEB"t 1D'#If ___ _ —From 0_ To 20 , Ft. BENTONIT GRAVITY
( applicable] .From To f Ft. 52 BAGS
WELL CONSTRUCTION PERMIT#384364 From To 1 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 9/28/2023 From To 'Ft. in. in.
TIME COMPLETED 0300 AM II PM OX From To Ft. in. in.
4.WELL LOCATION: 10.SAND/GRAVEL PACK:
CITY: CRESTON • COUNTY ASHE Depth Size Material
From To ' Ft.
OFF FLATWOODS RD OFF FORGE CREEK RD OF From To .Ft. t— -, a,..
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) From To I Ft. 1, 6..,'i..,_; t,, ;� •
TOPOGRAPHIC/LAND SETTING: OCT 6 -
0 Slope 0 Valley 0 Flat 0 Ridge 0 Other I o2023
(check appropriate box) 11. DRILLING LOG i�
l May be in degrees, From To I Formatipt q),V9sl•,„..,,. l �,,
LATITUDE _ minutes,seconds or 0 60 DIRT MUD S. 1
i.wr rr.•,}
LONGITUDE OG
in a decimal format 60 90 GRANITE• ��'r''
— — 90 91 VAIN
Latitude/longitude source: X GPS 0 Topographic map 91 120 LIMESTONE
(location of well must be shown on a USGS topo map and 120 160 GRANITE;
attached to this form if not using GPS) • 160 161 CREVIS I
161 200 LIMESTONE QUARTZ
5.WELL OWNER l
OWNER'S NAME DEBORAH HANLEY
STREET ADDRESS 8719 CASA DEL RIO DR
SHERRILS FORD NC 28673 .
City or Town State Zip Code
( 954 )- 261-4352
Area code- Phone number . 12. REMARKS: '
25 GPM 90-91 I
6.WELL DETAILS: 25 GPM 160-161
a. TOTAL DEPTH: 200
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: 10 FT. RECORD
AS BEEN PR IDED TO THAt.:.
EIWELL OWNER.
(Use"+"if Above Top of Casing) // //,�/ 1-a1.023
d. TOP OF CASING IS 1 FT.Above Land Surface* //
*Top of casing terminated at/or below land surface may require SIGN A TURE OF CERTIFIED WELL CONTRACTOR DATE
a variance in accordance with 15A NCAC 2C.0118. RANDALL MAIN ,
e. YIELD(gpm): 50 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'i Mgt.; Form GW-la
1617 Mail Service Center-Raleigh, NC 27699-1617 Phone No.[phone] ext 568. Rev.3/07
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