GW1-2022-09215_Well Construction - GW1_20220930

srA7r-.,'ts,
r RESIDENTL4L WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division;of Water Quality
WELL CONTRACTOR CERTIFICATION# 2669 210141.
i
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 45
KENNETH JORDAN g. WATER ZONES(depth):
Well Contractor(Individual)Name From 61 To 65 From 117 To 121
DEWEY WRIGHT WELL& PUMP CO., INC From To From To
Well Contractor Company Name From To From To
STREET ADDRESS PO BOX 308 7. CASING: Thickness/
BOONE NC 28607 Depth Diameter Weight Material
From 0 To 61 Ft. 6 1/8 350 PVC:
City or Town State Zip Code From To Ft.
8( 28 )-264-2651 From To Ft.
Area code- Phone number
2.WELL INFORMATION: 8. GROUT: Depth Material Method
From 0 -- ----To 20 Ft:--BENTONIT —_GRAVITY
SITE WELL ID#(if applicable) From To Ft. 19 BAGS
WELL CONSTRUCTION PERMIT# 170162 From To Ft.
OTHER ASSOCIATED PERMIT#(if applicable)
9. SCREEN: Depth I Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply Ik From To Ft. in. in.
DATE DRILLED 09/20/2022 From To Ft. in. in.
TIME COMPLETED 03:00 AM D PM Ox From To Ft. in. in.
4.WELL LOCATION: 10.SAND/GRAVEL PACK:
CITY: VILAS COUNTY WATAUGA Depth Size Material
From To Ft.
140 YASMIN LN OFF BURL LAWRENCE RD From To Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) From To Ft.
TOPOGRAPHIC/LAND SETTING:
0 Slope 0 Valley 0 Flat 0 Ridge 0 Other 11. DRILLING LOG
(check appropriate box)
May be in degrees, From To Formation Description
LATITUDE — — minutes,seconds or 0 30 RED SLATE
LONGITUDE. in a decimal format 30 61 GRANITE
— — 61 65 SHALE ROCK
Latitude/longitude source: o GPS o Topographic map 65 117 GRANITE
(location of well must be shown on a USGS topo map and 117 121 FLINTIWHITE QUARTZ
attached to this form if not using GPS) 121 240 GRANITE
5.WELL OWNER
OWNER'S NAME JOHN FULLER
STREET ADDRESS 6090 LEXINGTON AVE
PORTAGE IN 46368 _ �, �• .. =`6-' .F�L.•:d
City or Town State Zip Code _
( ) 1 e ou 2Z
Area code- Phone number 12. REMARKS:
0.5 GPM 61 -65 {n 3� �;.C:j Uri1
6.WELL DETAILS: %
11.5 GPM 117- 121
a. TOTAL DEPTH: 240
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO% I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
c. WATER LEVEL Below Top of Casing: 22 FT. RECORD HAS PFN PROVIDED TO THE WELL OWNER.
(Use"+"if Above Top of Casing)
d. TOP OF CASING IS 1 FT.Above Land Surface'
*Top of casing terminated atlor below land surface may require SIGNATUR CERTIFIED WELL CONTRACTOR DATE
a variance in accordance with 15A NCAC 2C.0118. KENNETH JORDAN i
i
e. YIELD(gpm): 12 METHOD OF TEST AIR PRINTED NAME OF PERSON CONSTRUCTING THE WELL
I
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt., Form GW-1a
1617 Mail Service Center—Raleigh, NC 27699-1617 Phone No.[phone] ext 568. Rev.3/07

CI
lJ
i
t
i
I
I
I
is