GW1-2021-00542_Well Construction - GW1_20210219

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.: RESIDENTIAL WELL CONSTRUCTION RECO,RI)rr^atlen i'rcces5ing Uni#
North Carolina Department of Environment and Natural Resources-Division of Water Qualff j( R 5SC(ipn
'�, �• WELL CONTRACTOR CERTIFICATION# 2W9 L90239.2
1.WELL`CONTRACTOR: f. DISINFECTION:Type HTH Amount 89
KENNY JORDAN g. WATER ZONES(depth):
Well Contractor(Individual Name) From 663 To 665 From TO
DEWEY WRIGHT WELL &PUMP CO., INC. From To From To
Well Contractor Company Name From To From To
STREET ADDRESS P.O.BOX 308 6.CASING: Thickness/
BOONE NC 28W7 Depth Diameter Weight Material
From 0 To 74 Ft. 61t4 .188 OALV
City or Town State Zip Code From To Ft.
( $2$ )-2Z4-2651 From To Ft.
Area code-Phone number 7.GROUT: Depth Material Method
2.WELL INFORMATION: From 0 To 22 Ft. BENTO1M Gravity Flow
-
SITE WELL ID#(if applicable) From To Ft. 33 BAGS
STATE WELL PERMIT#(if applicable) From To Ft.
DWO or OTHER PERMIT#(if applicable) InP6M &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply Q( From To Ft. in. in.
DATE DRILLED 1/2512021 From-To- Ft. in. in.
TIME COMPLETED 03:00 AM❑ PM i11i From To Ft. in. in.
9.SAND/GRAVEL PACK: -
3.WELL LOCATION:
Depth Size Material
CITY: BLOWINGROCK COUNTY CALDVJ=L From To Ft.
8211 SHOWY RIDGE WAY OFF DANCING BEAR IN 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) 0 62 nIRT
May be in degrees,
LATITUDE 3 N36.06.394 minutes,seconds or 62 74 BLUE GRANITE
LONGITUDE W081'46.063 in a decimal format 74 663 GRAY/BLUE GRANITE
Latitude/longitude source: LXGPS ❑Topographic map 663 655 BIG OUARTZ/CREVICE
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4.WELL OWNER
OWNER'S NAME MIKE POPE
STREET ADDRESS 12142ND AVENUE CT.
9CKORY. NC. 28601
City or Town State Zip Code
238-8284
Area code-Phone number
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 665 100 Gm 66q-665
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO
c. WATER LEVEL Below Top of Casing: 234 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 EN PRO DED 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.0118 SIGNATURE OF TIRED WELL CONTRACTOR DATE
e. YIELD(gpm): 100 METHOD OF TEST Air K;= N)4 -QRQAN
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
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