GW1-2021-04575_Well Construction - GW1_20210429

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- RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
2669 210016
WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR:
KENNY JORDAN f. DISINFECTION:Type HTH Amount 45
g. WATER ZONES(depth):
Well Contractor(Individual Name) From 200 To 02 From To
DEWEY WRIGHT WELL &PUMP CO., INC.
From To From To
Well Contractor Company Name
P.0.BOX 308 From To From To
STREET ADDRESS 6.CASING: Thickness/
BOONS NC 28607
From ial
ODToth 53 Ft. Diameter61/4 188 GALMate rV
City or Town State Zip Code From To Ft.
( $28 )_264-2651 From To Ft.
Area code-Phone number
2.WELL INFORMATION: 7.GROUT: Depth i Material Method
From 0 To 20 Ft.BENTONiT Gravity Flow:
- - SITE WEL-LAD#(if-applicable) — --- -- - - - - - - -- From-_ --To--- Ft - --- -
STATE WELL PERMIT#(if applicable) From To Ft.
DWO or OTHER PERMIT#(If applicable) &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply From To Ft. in. in.
DATE DRILLED 3/31/2021 yy From To Ft. in. in.
TIME COMPLETED UTOD AM❑ PM U From To Ft. in. in.
9.SAND/GRAVEL PACK:
3.WELL LOCATION:
Depth Size Material
CITY: AG WIILL WATAUGA
COUNTY From To Ft.
OFF bM-;.DALE RD.OFF BE' HIM RD.OFF 321 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 40 MUDIGRAVEL
N36*19.604 May be in degrees, 40 200 BLUE GRANITE
LATITUDE 3 minutes,seconds or
LONGITUDE in a decimal format 200 202 BIG CREVICE
Latitude/longitude source: CKGPS ❑Topographic map 202 225 BLUE GRANITE
(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 NAMEDALE CORNETT
STREET ADDRESSPO BOX 172,
VILA.S NC 22M m
City or Town State Zip Code
( (8= )_ 964-W2. n n 9 2021
Area code-Phone number
5.WELL DETAILS: 11.REMARKS: Information Proressing Unit
a. TOTAL DEPTH: 225 30 GPM 200-202 DWR Section
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO19
c. WATER LEVEL Below Top of Casing: 5 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
a variance in accordance with 15A NCAC 2C.0118 SIGN6rDR5 OF CERTIFIED WELL CONTRACTOR DATE
i ,
e. YIELD(gpm): 30 METHOD OF TEST A>t 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,INC 27699-1617 Phone No.[phone] ext 568. Rev.7/05
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