GW1-2021-06937_Well Construction - GW1_20210505

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RESIDENTIAL WELL CONSTRUCTION RECORD
- I C North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 2$69 200202
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 56
KENNY JORDAN g. WATER ZONES(depth): ,
Well Contractor(Individual Name) From 120 To From 147To
DEWEY WRIGHT WELL&PUMP CO., INC. From 235 To From To
Well Contractor Company Name From To From To
STREET ADDRESS P.O.BOX 308 6.CASING: Thickness/
BOONE NC 28607 Depth Diameter Weight Material
From 0 To 80 Ft. 6118 .350 PVC
City or Town State Zip Code, From To Ft:
( 828 )-264-2651 From To Ft.
Area code-Phone number
2.WELL INFORMATION: 7.GROUT: Depth f Material Method
From 0 To 20 Ft: BENTONIT Gravity Flow
SITE WELL ID#of applicable) From To Ft. 18BAGS
STATE WELL PERMIT#(if applicable) From To Ft
DWQ or OTHER PERMIT#(if applicable) 330097 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply From To Ft. in. in.
DATE DRILLED V14/2021 From To Ft'. in. in.
TIME COMPLETED 03:00 AM❑ PM From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
Depth Size Material
CITY: SST JE FMO14 COUNTY A—%M" From To Ft.
OFF SEVERT RD OFF 163 OFF IDLEWILD OFF 2210 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) May be in degrees, 0 47 SAND/SHELL ROCK
LATITUDE 3 36.331008- minutes,seconds or 47 120 GRANITE -
LONGITUDE "~ _$1.404$61 .in a decimal format120 120, ;, CREVICE
Latitude/longitude source: LYGPS ❑Topographic map 120 147 GRANITE
(location of well must be shown on a USGS topo map and 147 147 CREVICE
attached to this form if not using GPS) 147 235 GRANITE
4.WELL OWNER 235 235. CREVICE
OWNER'S NAME FP-4'MpHILL 235 320 GRANITE
-
STREET ADDRESS 3805 BROGDEN RD; -
SbAIlTFn;= - NC 27577
City or Town State Zip Code
(( 919) )- 868-8653
Area code-Phone number lap \3\Z\\
5.WELL DETAILS: 11.REMARKS: t\?Volce
a. TOTAL DEPTH: 320 2 GPM 120- 1 GPM 147 T„fnR S
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO KI 2 GPM 235-
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 at/or below land surface may require �� �"o`l�' -07
a variance in accordance with 15A NCAC 2C.0118 SIGNAT CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): 5 METHOD OF TEST Air KENNY 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-1a
1617 Mail Service Center-Raleigh,NC 27699-1617 Phone No.[phone] ext 568.,' Rev.7/05

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