GW1-2021-05183_Well Construction - GW1_20210527

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RESIDENTIAL WELL CONSTRUCTION RECORID
North Carolina Department of Environment and Natural Resources-Division of Water:Quality
WELL CONTRACTOR CERTIFICATION# 2669 210019
1.WELL CONTRACTOR:
f. DISINFECTION:Type �HTH Amount . 86
KENNY JORDAN g. WATER ZONES(depth):
Well Contractor(Individual Name) From 407 To 40S 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/
BOONS NC 28607 Depth Diameter Weight Material
From To 45 Ft. 6 1 of ,35Q_ Pyc
City or Town State Zip Code From To Ft.
( g2$ ) 264-2651 From To Ft.
Area code-Phone number
7.GROUT Depth i Material Method
2.WELL INFORMATION:
From�0 To_110 Ft. EM4TM= Gynimm=
SITE WELL ID#(f applicable) — _ -- — —From.-- —To- -- Ft: -- . - - --- -
STATE WELL PERMIT#(if applicable) From To Ft.
DWQ or OTHER PERMIT#fdapplicable) 437619 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply LA From To Ft. in. in.
DATE DRILLED_Q30/2021 From To Ft. in. in.
TIME COMPLETED Al-OD AM❑ PM W From To Ft. in. in.
9.SAND/GRAVEL PACK:
3.WELL LOCATION:
Depth Size Material
CITY. BANNER ELK COUNTY VJ11112= From TO Ft.
From To Ft.
4389ROMINGERRD OFF HW-321-OFF HW 421 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 32 DIRT
May be in degrees,
LATITUDE 3 NWOB 774• minutes,seconds or 32 45 GRAY GRANITE
LONGITUDE _ W081+50-454 in a decimal format 4S 407 GRAY QUARTZ/GRANI
Latitude/longitude source: C*GPS ❑Topographic map d07 408- QUARTZICREVICE
(location of well must be shown on a USGS topo map and A08 - A25__ GRAY GRANITE
attached to this form if not using GPS)
4.WELL OWNER
OWNER'S NAME C011MM Tg33.n=
STREET ADDRESSit I H0Ng j!T)ZW t N
II )or oULK State NC Zip
Area code-AheMber
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 42S 20 GPM 407 409
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO k,
c. WATER LEVEL Below Top of Casing: 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 aVor below land surface may require I s- 7-a1
a variance in accordance with 15A NCAC 2C.0118 SIGNATURE OF CEP91FIED WELL CONTRACTOR DATE
e. YIELD(gpm): 20 METHOD OF TEST PRINT IYE OF PEIRSCINCONSTRUCTING 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
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