GW1-2021-01637_Well Construction - GW1_20210329

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3 RESIDENTIAL WELL CONSTRUCTION RECORD
" North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 26LV 200229
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount
46
KENNY JORDAN g, WATER ZONES(depth):
Well Contractor(individual Name) From 140 To From it TO IRS
DEVVEY WRIGHT WELL&PUMP CO., INC. From us To From 240 TO
Well Contractor Company Name From To From To
STREET ADDRESS P.O.BOX 306 &CASING: Thickness/
BOONE NC 26607 Depth Diameter Weight Material
From 0 To_& Ft. 61l8 .350 PVC
City or Town State Zip Code From Tc Ft.
( )-264-2651 From To Ft.
Area code-Phone number
2.WELL INFORMATION: ].GROUT: Depth Material Method
From 0 TO--20- Ft. BENTONIT CirwitY Flow
SITE WELL ID#atappacr From To Ft. IRBAGR
STATE WELL PERMIT#(a applicable) From To Ft.
DWO or OTHER PERMIT#(Jappirable) 763449 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply CR From To Ft. in. _in.
DATE DRILLED III&/2021 From To Ft. in. _in.
TIME COMPLETED 03:00 AM❑ PM 0 From To Ft. in. in.
9.SAND/GRAVEL PACK:
3.WELL LOCATION:
Depth Size Material
CITY: BANNER MA COUNTY AVERY From7bi Ft.
From_ Tc Ft.
1501 S BEECH MM PKWY BANNER ELK NC OFF H 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 03 SANDSTONE
May he in degrees,
LATITUDE 3 N3tS+10]1i minutes,sxonds or Ka 1,10 _ GRANITE
LONGITUDE W81*5229 inadximal format i14 140 CREl9CE
Latitudeflongitude source: LJ(GPS ❑Topographic map lAn 185 aRANiTF
(location of well must be shown on a USGS topo map and I VAR kmin
attached to this form if not using GPS) 1M 115 rRAMITEA IMFCrf1NF
4.WELL OWNER 214 215 rRFkICF
OWNER'S NAME SRN COOK � a yp GRANITE
STREET ADDRESS'/.MOUNTAIN CONSTRUCTION RO ROX 1 yin yq �r ,w Fz.
BOONS NC 2860r7 !300 CRMIITiv Ea,
City or Town State Zip Code
( 8= - 963-6090 MAR 2 9 7021
Area code-Phone number
S.WELL DETAILS: 11.REMARKS: IrlfOrfil3tion Processing I
a. TOTAL DEPTH: 300 2 am 140- -;am I"-lee DWR Section
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOi] tam 91C- 2-fsM 240_
c. WATER LEVEL Below Top of Casing: 60 FT DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
(Use"+"if Above Top 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 Fr.Above Land Surface`
Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C.0118 SIGNATURE,OPCERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): 11 METHOD OF TEST T:.
PRINT 8?Rft 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