GW1-2021-06883_Well Construction - GW1_20210505

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RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 26S 1 210M
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 48
KENNYJORDAN
g. WATER ZONES(depth): '
Well Contractor(Individual Name) From 135 To From is TO
DEWEY WRIGHT WELL&PUMP CO., INC. From 220 To From 265To
Well Contractor Company Name From TO From To
STREET ADDRESS P.O.BOX 308- 6.CASING: Thickness/
$OONE NC 286(Y7 Depth Diameter Weight Material
From 0 Tom Ft. 6118 -350 PVC
City or Town State Zip Code From To Ft.
( = )-2664-2651 From To Ft.
Area code-Phone number 7.GROUT: Depth Material Method
2.WELL INFORMATION:
From 0 To 20 Ft. AM4TOWIT Gravity Inew
SITE WELL ID#(if applicable)} _ _, _---.-_ -_-.From-- To— -- Ft -2l BERGS — —
STATE WELL PERMIT#(if applicable) From To Ft.
DWO or OTHER PERMIT#(if applicable) 317541 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply C From To Ft. in. in.
DATE DRILLED 4/24/2021 From To Ft. in. in.
TIME COMPLETED 03:00 AM❑ PM N From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
Depth Size Material
CITY: VJ=JEFFERSON COUNTY ASHfi From To Ft.
OFF GRANDVIEW OFF PERRY RD OFF BUFFALO R 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 26 SAND/CLAY
May be in degrees,
LATITUDE 3 36.408777 minutes,seconds or 26 135 GRANITE
LONGITUDE -81.549819 in a decimal format 135 135 CREVICE
Latitude/longitude source: MPS ❑Topographic map 135 185 GRANITE
(location of well must be shown on a USGS topo map and 185 185 CREVICE
attached to this form if not using GPS) 185 220 GRANITE
4.WELL OWNER 220 2" CRI2VICF
OWNER'S NAME JOHN GHAREEB 220 265 r;RANITF
STREET ADDRESS%.MASTERCRAtF°T CRC LLC. PO,BOX_134--- -_.:-.265-..;_265 _ CR BACE.
WEST JE FERSON NC 29694 265 sm
City or Town State Zip Code
Area(336) 877-7735 SAD
d-Phone number pG ' �v
5.WELLDETAILS: 11.REMARKS: `erEolt .'�0 SAC
a. TOTAL DEPTH: 300 QS[.M& 1-35_ Q,S ma i85-
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOW 1 GZA '720- 2 G A265
c. WATER LEVEL Below Top of Casing: 60 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 B N PROVIDED To THE WELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land Surface' nn q
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C.0118 SIGNATURE% TIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): 4 METHOD OF TEST Air KF=NNlY.IlORQA
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.iRev.7/05
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