GW1-2021-01635_Well Construction - GW1_20210329

RESIDENTIAL WELL CONSTRUCTION RECORD
" North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 26M 200739
1.WELL CONTRACTOR: f. DISINFECTION:Type 14TI4 Amount 41
KENNYJORDAN
g. WATER ZONES(depth):
Well Contractor(Individual Name) From 140 To 140 From 2110To 2ni
OEWEY WRIGHT WELL &PUMP CO., INC. From TO From To
Well Contractor Company Name From To From To
STREET ADDRESS A 0.BOX 308 6.CASING: Thickness/
BOONE NC 28607 Depth Diameter Weight Material
From,To 60 Ft. 61/8 _150— PVC
City or Town State Zip Code From To Ft.
( 8M )-264-2651 From To Ft.
Area code-Phone number
2.WELL INFORMATION: 7.GROUT: Depth Material Method
From 0 To ..20_ Ft. BHNTO1= Caratrity Flow
SITE WELL ID#(IfaPPlloable) From To Ft. 401RAGS
STATE WELL PERMIT#(d applicable) From To Ft.
DWO or OTHER PERMIT#fd applse e) 147184 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply Ct FromTo Ft._in. _in.
DATE DRILLED 2/27/2021 From To Ft. in. in.
TIME COMPLETED 03:00 AM❑ PM IN From Tc Ft._in. _in.
9.SAND/GRAVEL PACK:
3.WELL LOCATION:
Depth Size Material
CITY: Vn=JEFFMON COUNTY AMIE From_ To Ft.
From 7bi Ft. _
LOT 19 OFF QUAIL LN OFF W01"ACK LN OFF BO From To Ft. _
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
❑Slope ❑valley ❑Flat O Ridge O Other From To Formation Description
(check appropriate box) May be in degrees, n tl S/1Nn1rRAVPL
LATITUDE 3 N35*57777 minutes,semrds or A2 11n PRANiTle
LONGITUDE W091*56.567 ma decwal format 1I0 1I0 _ CREVICE
Iatitudeflongitude source: AUPS ❑Topographicmap 1An 2nn GRANITP
(location of well must be shown on a LEGS topo map and —200 20S Vain
attached to this form if not using GPS) 205 2A S GRANITE
4.WELL OWNER
OWNER'S NAME JAM M R CAUDILL ry r
STREET ADDRESS 117 R JOHNSON ST_
CART NC 27513 o e G 902
City or Town State Zip Code
(9119)- 271-3516 proCeSSIng
Area code-Phone number DYJR S
5.WELL DETAILS: U.REMARKS:
a. TOTAL DEPTH: 245 2 GPM 140-140 2 GPM 200-20S
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO�
c. WATER LEVEL Below Top of Casing: 40 FT. I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
(Use"+"if Above Top of Casing) 1SA NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land Surface' 01,
Top of casing terminated at/or below land surface may require 7
a variance In accordance with 15A NCAC 2C.0118 SIG le CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): 4 ._METHOD OF TEST Air KFNNY -nRIILN
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.7/05