GW1--07198_Well Construction - GW1_20231108

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,� '•�' ° 4'4•• RESIDENTIAL WELL CONSTRUCTION RECORD
/� a North Carolina Department of Environment and Natural Resources-Division of Water Quality
Nt.,w...�) WELL CONTRACTOR CERTIFICATION# 3867 230053
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1.WELL CONTRACTOR: f. DISINFECTION:Type FiTH Amount 71
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RANDALL MAIN
g. WATER ZONES(depth)':
Well Contractor(Individual)Name From_ To
From 210 To 211 I
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 0 To 40 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 20 'Ft.. BENTONIT GRAVITY
From To 1 Ft. 13 BAGS
.WELL CONSTRUCTION PERMIT#379758 From To I Ft.
i
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 10/26/2023 From To Ft. in. in.
TIME COMPLETED 0300 AM I PM OX From To Ft. in. in.
4.WELL LOCATION: 10.SAND/GRAVEL PACK:
CITY: SUGAR GROVE COUNTY WATAUGA Depth Size Material
From To Ft.
OFF IVAN TRIVETTE OFF HWY 321 N OFF HWY 42 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 — 36.25082N minutes,seconds or 0 15 DIRT..
LONGITUDE 81•77827W in a decimal format 15 35 UNCONSOI IDATFD ROCK
— — 35 120 GRANITE
Latitude/longitude source: X GPS o Topographic map 120 160 GRANITE QUARTZ
• (location of well must be shown on a USGS topo map and 160 200 SHALE,LIMESTONE
attached to this form if not using GPS) 200 210 GRANITE
210 211 VAIN I
5.WELL OWNER 211 280 GREY GRANITE
OWNER'S NAME DAVID&LESLEY BROWDER 280 400 GREY GRANITE BLACK GRANITE
STREET ADDRESS 402 WILDWOOD AVE
ROCKY MOUNT NC 27803 I =,
City or Town State Zip Code "' °--•.. '.1,t,J yi1
( 828 • )_ 406-9643 NOV S 2Q23
Area code- Phone number 12. REMARKS:
7.5 GPM 210-211 I„ •I
6.WELL DETAILS: " • 1--_•_• •:'-• UFLt
a. TOTAL DEPTH: 400 I
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: 50 FT. RECORD,-•S BEEN PROV.:,.■TO THE WELL OWNER.
(Use"+"if Above Top of Casing) / //
d. TOP OF CASING IS 1 FT.Above Land Surface*
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*Top of casing terminated at/or below land surface may require SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
a variance in accordance with 15A NCAC 2C.0118. RANDALL MAIN j
e. YIELD(gpm): 7.5 METHOD OF TEST AIR PRINTED NAME OF PERSON CONSTRUCTING THE WELL
I
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 568.1 1 Rev.3/07

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