GW1-2021-01369_Well Construction - GW1_20210329

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S RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 26 200M
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 54
KENNYJORDAN
g. WATER ZONES(depth):
Well Contractor(Individual Name) From 200 To 200 From 260To 260
DEWEY WRIGHT WELL &PUMP CO.,INC. From TO From To
Well Contractor Company Name From To From To
STREET ADDRESS P.O.BOX 308 S.CASING: Thickness/
BOONE NC 28607 Depth Diameter Weight Material
From 0 To 176 Ft. 6114 .188 GALV
City or Town State Zip Code From To Ft.
( 828 )-264-2651 From To Ft.
Area code-Phone number 7.GROUT: Depth Material Method
2.WELL INFORMATION: Front-0 To 20 Ft. BENTONIT GirwayFlow
SITE WELL ID#of appii a ) Fmm To Ft. 32BAGS
STATE WELL PERMIT#fit apolcatlel From To Ft.
DWO or OTHER PERMIT#(eappeeeblel 306704 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply Q FromTo Ft. in. in.
DATE DRILLED 3/11/2021 From To Ft. in. in.
TIME COMPLETED 03:00 AM❑ PM 11i From To Ft._in. _in.
9.SAND/GRAVEL PACK
3.WELL LOCATION:
PINEY CR= �Y Depth Size Material
CRY: COUNTY From To Ft.
OFF BLEVINSHOLLOW OFF OFF TONA OFF ICNGS From _To Ft. _
From To Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Percel,Zip Code)
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
❑Slope ❑Valley ❑Flat ❑Ridge ❑Other From TO Formation Description
(check appropriate box) 0 152 CLAY/GRAVEL
Maybe in degrees,
LATITUDE 3 _ minutes,seconds or 112 200 GRANITE
LONGITUDE _ in a decimal format 200 200 CREVICE
latitudellongitude source: LXGPS ❑Topogrephicmap 200 250 GRANITE
(location of well must be shown on a USGS topo map and 250 250 CREVCE
attached to this form if not using GPS) 250 300 GRANITE
4.WELL OWNER
OWNER'S NAME AARON BURCHhTTB _
STREET ADDRESS%SIDGEMCK HOMES. I105 JOHNSON RI
STATESV= NC 2Wn
City or Town State Zip Code M
(c 336) I- 467-2538 it
Area code-Phone number lni Orttt3Imrceriinn
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 300 1 GPM 200-200 1 GM 260-260
b. DOES WELL REPLACE EXISTING WELL? YES❑ NORI
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) 15A 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 attor below land surface may require
a variance in accordance with 15A NCAC 2C.0118 SI CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): 2 METHOD OF TEST Ak KtANY 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-ta
1617 Mail Service Center- Raleigh, NC 27699-1617 Phone No. [phone] ext 568. Rev.7/05