GW1-2021-06987_Well Construction - GW1_20210505

a�a SrATF o
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
♦ �Q11**M Va+" 669
WELL CONTRACTOR CERTIFICATION# 2 210028
I
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 156
KENNY JORDAN
g. WATER ZONES(depth):
Well Contractor(Individual Name) From 194 To 195 From 8S8TO 899
DEWEY WRIGHT WELL &PUMP CO.. INC.
From To � From To
Well Contractor Company Name
P.O.BOX 30$ From To .From To
STREET ADDRESS 6.CASING: Thickness/
Depth Diameter Weight Material
BOONS NC °28607 From To Ft:
City or Town State Zip Code From To Ft
264-2651 From To Ft.
Area code-Phone number 7.GROUT: Depth Material Method
2.WELL INFORMATION: From 0 To---20- Ft. BENTONPT &avityFlow
- SITE WELL ID#pf applicable) -- - - From - To - - Ft 19BAG5' ------- -—
STATE WELL PERMIT#(if applicable) From To Ft.
DWQ or OTHER PERMIT#(if applicable) 18M17 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply Cat From To Ft. in. in.
DATE DRILLED 4/19/2021 From To Ft. in. in.
TIME COMPLETED 03:00 AM❑ PM Of From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
Depth Size Material
CITY: BANNSRSLK COUNTY wa s= From To Ft.
272 CLAM CREST{RD OFF HWY 105 From _To Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) From To Ft.
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
❑Slope ❑Valley ❑Flat ❑Ridge ❑Other From To Formation Description
(check appropriate box)
May be in degrees, n M DBT
LATITUDE 3 _ 36.162386 minutes,seconds or AO 19d A'I IF GRANITE
LONGITUDE 81.766204 in a decimal format 194 195 QUART rr_REM _F
Latitude/longitude source: L)CGPS ❑Topographic map 195 BOB BLuFmRAY GRANITE
(location of well must be shown on a USGS topo map and 88B i3es 0UART21QREyCF
attached to this form if not using GPS) an 925 DARK GRAY GRANITE
4.WELL OWNER ^-*
OWNER'S NAME SUSAN M[MM
STREET ADDRESS PO BOX 143. n * y
BOONE NC 2g6011 ��
City or Town State Zip Code
?73-3499 '(�f� �1V
Area code-Phone number (i s 5 C1)
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 925 0 5 GM 194- 195 2 GPM M-M
-
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOJO
c. WATER LEVEL Below Top of Casing: 99 FT. I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
(Else"+"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 I FT Above Land Surface*
*Top of casing terminated at/or below land surface may require �f- cr
a variance in accordance with 15A NCAC 2C.0118 §GNATAX-T&FICERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): 2.5 METHOD OF TEST =Air
PRINTED NAME F PE SON CONSTRUCTING THE WELL
f ;
Submit the original to the Division of Water Quality within 30 days.Attn:Information Mgt., Form GW-1 a
1617 Mail Service Center-Raleigh, NC 27699-1617 Phone No.[phone] ext 568.' Rev.7/05

I;TH
.3s'�':���_j
JP� t- .0 9
r M
c nR vjivza ,-D _.I MS e37/faR v-S try
v _
EO
`fit_? .?
B 3P,j5?,0ISTP,fAU:) B£!t 4Et
�TIMdd 1,7: (AA@3Uj3
�TIL^ :7�c1 Yi,R7 it^ikft 8a�? e38
X
IN
I�?4(71P