265224 20191203 Mahew Residence

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources - Division of Water Quality'
WELLCONTRACTOR
1.WELL CONTRACTOR:
CODY SLATE
Well Contractor (Individual Name)
DONEY WRIGHT WELL & PUMP CO., INC.
Well Contractor Company Name
STREET ADDRESS P. O. BOX 308
BOONE NC 28607
City or Town State Zip Code
( 828 )-264-2651
Area code - Phone number
2.WELL INFORMATION:
SITE WELL ID #(ifapplicable)
STATE WELL PERMIT #(if applicable)
DWO or OTHER PERMIT #(li apprcabla) 265244
WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED IV3/2019
TIME COMPLETED 03:00 AM ❑ PM &
3. WELL LOCATION:
CITY: TODD COUNTY ASHE
OFF GREEN IMADOWS DR OFF BROWN RD OFF R
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑ Slope ❑ Valley O Flat 0 Ridge 0 Other
(check appropriate box)
May be in degrees,
LATITUDE 3 36*11.332 minutes, seconds or
LONGITUDE. ,y
081`4069 in a decimal format
Latitude/longitude source: CIGPS ❑ Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4.WELL OWNER
OWNER'S NAMEJOSH & TAMMY MAYEEW
STREET ADDRESe/- BUILT HIGH CUSTOM HOMES TRl' 1F
MOCKSV= NC 27029
City or Town State Zip Code
( (8= j _ 610-IM5
Area code - Phone number
5.WELL DETAILS:
a. TOTAL DEPTH: 140
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NOXI
c. WATER LEVEL Below Top of Casing: 20 FT.
(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
a variance in accordance with 15A NCAC 2C .0118
e. YIELD (gpni 30 METHOD OF TEST Air
4395
I. DISINFECTION: Type HTH Amount 25
g. WATER ZONES (depth):
From 115 To lid From To
From To— From To
From To From To
6.CASING: Thickness/
Depth Diameter Weight Material
From 0 To 59 Ft. 6119 .350 PVC
From To Ft.
From To - Ft.
7.GROUT: Depth Material Method
From 0 To 21 Ft. BENTONIT GravitVFlow
From To Ft.
From To Ft.
B.SCREEN: Depth Diameter Slot Size Material
From - To Ft. in. in.
From To Ft. in. _in.
From To Ft. in. _in.
9.SAND/GRAVEL PACK:
Depth Size Material
From -To Ft.
From _ _To Ft.
From To Ft.
10. DRILLING LOG
From To Formation Description
0 54 DIRT
54 115 GRANITE
115 116 CREVICE
196 140 GRANITE
\1 C D4pwtme
Enylronmpntal 1.1ality
Received
q
Sal
Office s Via.
11. REMARKS:-
30 GPM 115-116 '
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECOR HAS BEEN FROM ED TO THE WELL OWNER.
SIGN E OF CERTIFIED WELL CONTRACTOR DATE
COD`I SLATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt., Form GW-1 a
1617 Mail Service Center -Raleigh, NC 27699-1617 Phone No. [phone] ext 568. Rev. 7/05