GW1--07904_Well Construction - GW1_20231205

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r f '• RESIDENTIAL WELL CONSTRUCTION RECORD
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` `, trip i North Carolina Department of Environment and Natural Resources-Division of Water Quality
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' `'``��.'"� WELL CONTRACTOR CERTIFICATION# 3867 210183 -
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 53
RANDALL MAIN g. WATER ZONES(depth):
Well Contractor(Individual)Name From 140 To 142 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 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
From 0 To 20 Ft. BENTONIT GRAVITY
SITE WELL ID#(if applicable) _ __ _ From_ To-- _ .-,Ft..-20-BAGS-'--- ------
WELL CONSTRUCTION PERMIT# 184270 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 11/6/2023 From To I Ft. in. in.
TIME COMPLETED 0300 AM 0 PM OX From To Ft. in. in.
4.WELL LOCATION: 10.SAND/GRAVEL PACK:
CITY: BANNER ELK COUNTY WATAUGA Depth Size Material
From To Ft.
OFF ANDY HICKS OFF WORLEY RD OFF 194 OFF 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
(check appropriate box) 11. DRILLING LOG
May be in degrees, From To Formation Description
LATITUDE _ _ minutes,seconds or 0 35 DIRT BOULDERS
LONGITUDE in a decimal format 35 140 GREY GRANITE PINK OUART7
— — 140 142 CREVICE
Latitude/longitude source: X GPS o Topographic map 142 160 GRANITE
(location of well must be shown on a USGS topo map and 160 180 SHALE
attached to this form if not using GPS) 180 200 BLACK,GRANITE
200 280 GRANITE PINK QUARTZ
5.WELL OWNER 280 405 GRANITE .,� . - -.., r,,.....
OWNER'S NAME ANDREW BOUND �r i--p r,a c a:
STREET ADDRESS PO BOX 691
VALLE CRUCIS NC 28691 - - - DEC 0 5 2023
City or Town State Zip Code
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(828 )_ 719-5266 • DW;::i°30i.;
Area code- Phone number 12. REMARKS:
30 GPM 140-142 . .
6.WELL DETAILS:
a. TOTAL DEPTH: 405
b. DOES WELL REPLACE EXISTING WELL? YES 0 NOX ' I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
C. WATER LEVEL Below Top of Casing: 150 FT. RECORD. :EEN PROVIDE!TO'THE WELL OWNER.
(Use"+"if Above Top of Casing) •
d. TOP OF CASING IS 1 FT.Above Land Surface* / � , ��, ))—!
*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
e. YIELD(gpm): 30 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-1a
1617 Mail Service Center—Raleigh, NC 27699-1617 Phone No."[phone] ext 568. Rev.3/07

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