GW1-2022-08804_Well Construction - GW1_20220909

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~ = RESIDENTIAL WELL CONSTRUCTION RECORD
o North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 2669 220M
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount A4
KENNY JOROM g. WATER ZONES(depth): i
Well Contractor(Individual Name) From ;I R To 1.71 1 From To
UEVVEY WRiGH T •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 2$60 Depth Diameter Weight Material
From 0 To--AO Ft: 61/A lift W('
City or Town State Zip Code From To Ft:
( 828 )264-2651 From To Ft.
Area code-Phone number
2.WELL INFORMATION: 7.GROUT- Depth Material Method
_f)From 0 To ��//'jjL-aFfBENTONIT Gram Mcw
SITE WELL ID'#(if applicable)- - - From To F08 RAGS
STATE WELL PERMIT#(if applicable) From To Ft.
DWO or OTHER PERMIT#(f applicable) 362282 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply$I From To Ft. in. in.
DATE DRILLED 8125/2022 From To Ft. in. in.
TIME COMPLETED 03:00 AM❑ PMXI From To Ft. in. in.
9.SAND/GRAVEL PACK:
3.WELL LOCATION:
Depth Size Material
CITY:BANNER FIX COUNTY WATAUGA From To Ft.
LOT 37 MONTEAGLE OFF SKY CAMP TR.AII.,OFF F 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) n F,n BROWN DIRTPSHALE I
May be in degrees,
LATITUDE 3 36190 111 minutes,seconds or Fin 118 iCRANIT !PINK SLATF
LONGITUDE 91-844401V in a decimal format 118 1211 SHALE ROCK
Latitude/longitude source: jl GPS ❑Topographic map 121 520 GRANITEIPINK SLATE
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS) _
4.WELL OWNER -3.a f V
OWNER'S NAMERjCAIRT) BREIISC j
STREET.ADDRES3�FARRKLL RH -PH - 1)_ 471 LONNIE HEALS
V'TT.AS AS(' 2Rt5Q2 .. ..-
City or Town State Zip Code
C( 8= 1-963-0277
Area code-Phone number
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 520 2 GPM I i R- 121
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOAE]
i
c. WATER LEVEL Below Top of Casing: 120 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 Td THE WELL OWNER.
d. TOP OF CASING IS I FT.Above Land Surface'
Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C.0118 SIGN r�' E ERTIRED WELL CONTRACTOR DATE
e. YIELD(gpm): 2 METHOD OF TEST Air
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days.Attn: Informatio ir 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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