GW1-2021-01636_Well Construction - GW1_20210329

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A . Q RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 2.6M 210005
1.WELL CONTRACTOR: I.
KENNY JORDAN DISINFECTION:Type HTH Amount ill
g. WATER ZONES(depth):
Well Contractor(Individual Name) From 210 To 210— From 480To 4@
DEWEY WRIGHT WELL&PUMP CO., INC. From____J_41<To 5V From To
Well Contractor Company Name From To From To
STREET ADDRESS P.O.BOX 308 &CASING: Thickness/
BOONS NC T8607 Depth Diameter Weight Material
From 0 Tom& Ft. R 1/R 75A Wz
City or Town State Zip Code From To Ft.
( US )-264-2651 From To Ft.
Area code-Phone number
2.WELL INFORMATION: 7.GROUT: Depth Material Method
From_O-To_]Q Ft. RRNTONTT C,reoity Rine
SITE WELL ID#fd applicable) Frorn—To Ft. 21 BAGS
STATE WELL PERMIT#(rt appii�aeie) From To Ft.
DWO or OTHER PERMIT#(nappiicabie) 320216 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply QX From To Ft. in. in.
DATE DRILLED 3/16=1 From To Ft._in. in.
TIME COMPLETED 03:00 AM❑ PM 01 From To Ft._in. _in.
9.SAND/GRAVE :L PACK
3.W ELL LOCATION:
Depth Size Material
CITY: Vam 2WFEWN COUNTY A14MIR FromToi Ft.
OFF CLAYBANK RD OFF HWY 88/194 OFF BWY 221 From_ To Ft. _
From To Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
❑Slope O Valley O Flat 0 Ridge J Other From To Formation Description
(check appropriate box) n LL SANIIIGRAVPI
May be in degrees,
LATITUDE 3 917 minutes,seconds or LL 9te rRAVFI
LONGITUDE W081*42,610 inadecimalfomlat Mn An CREACF
Latitude/longitude source: LkGPS ❑Topographicmap 230 400 `(RANITF
(location of well must be shown on a USGS topo map and utrl 400 CREVICE
attached to this form if not using GPS) M 540 GRANITE
4.WELL OWNER 540 540 CRP4CE
OWNER'S NAME TALON A TMM.Y ST0170RR sn 50p GRANIJF
STREET ADDRESS) S DEIGN BL_l_1.D PO ROY 52 L..
n1i GAP NC 28619
City or Town State Zip Code
( !S - 964-8486
Area code-Phone number r lien Proces5ln 11
5.W ELL DETAILS: 11.REMARKS: ��-�OTr—
a. TOTAL DEPTH: 600 OS om 210-210 0 S GPM 480-480
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO j@ I COW 540-540
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) ISA 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' `
Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C.0115 SIG CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): 2 METHODOFTEST Air KFNNV .nRnAN
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days.Attn:Information Mgt., Form GW-la
1617 Mail Service Center-Raleigh, NC 27699-1617 Phone No.[phone] ext 568. Rev.7/05