GW1-2021-00308_Well Construction - GW1_20210312

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.: .� RESIDENTIAL WELL CONSTRUCTION RECORD
M0191 .2021
CO North Carolina Department of Environment and Natural Resources-Division of Wat i, mt oo n Pr0^.E85ir'9 VI}il
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WELL CONTRACTOR CERTIFICATION# 266g 2100M
1.WELL CONTRACTOR: HTH Amount 45
f. DISINFECTION:Type
KENNY JORDAIV
g. WATER ZONES(depth):
Well Contractor(Individual Name) From 135 To 137 From 155To 157
DEVVEY MIGHT WELL &.PUMP CO., INC.
From To From To
Well Contractor Company Name From To From To
STREET ADDRESS P.O BOX 308 6.CASING: Thickness/
BOONE NC 2MM Depth Diameter Weight Material
From 0 To 81 Ft. 6118 .350 PVC
City or Town State Zip Code From - To Ft.
( 828 )-264-2651 From To Ft.
Area code-Phone number
2.WELL INFORMATION: 7.GROUT: Depth Material Method
From 0 To 20 Ft. BENTONIT Gravity Flow
SITE WELL ID#(if applicable) From To Ft. 17 BAGS
STATE WELL PERMIT#(if applicable) From TO Ft.
DWQ or OTHER PERMIT#(if applicable) 307092 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply l From To Ft. in. in.
DATE DRILLED 2/23/2021 From To Ft. in. in.
TIME COMPLETED 03:00 AM❑ PM L� From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
Depth Size Material
CITY: CRUWUM COUNTY ASM From _To Ft.
OFF COL FR.ANCIS RD OFF OLD 16 OFF 16 OFF 221 From _To Ft.
From To Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
❑Slope ❑Valley ❑Flat ❑Ridge ❑Other From To Formation Description
(check appropriate box) 0 30 DIRT
N36+20.817 May be in degrees,
LATITUDE 3 _ minutes,seconds or 30 40 GRANITEISHELL ROCI
LONGITUDE _
W081*42.610 in a decimal format 40 67 DIRT
Latitude/longitude source: IXGPS ❑Topographic map 67 135 GRANITE
(location of well must be shown on a USGS,topo map and 135 137 QUARTZ
attached to this form if not using GPS) 137 155 GRANITE
4.WELL OWNER 155 157 QUARTZ
OWNER'S NAME JPIM PHOPS 157 300 GRANITE
STREET ADDRESS 1384 WILWEIR FORD RD, -_
GRASSY CREEK NC 28631
City or Town State Zip Code
(3( 36) )- 977-8562
Area code-Phone number
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 300 1 GPM 135- 137 3 GPM 155- 157
b. DOES WELL REPLACE EXISTING WELL? YES❑ Noll
c. WATER LEVEL Below Top of Casing: 80 FT. I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
(Use"+"if Above Top of Casing) 15A NCAc 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
RECORD HAS EEN PROVIDED TO THE WELL OWNER.
d. TOP OF CASING IS 1 FT.Above.Land Surface* g s
"Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C.0118 SIGN E OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): 4 METHOD OF TEST Air KENNY JORDAN
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