GW1-2022-09556_Well Construction - GW1_20221021

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RESIDENTML WELL CONSTRUCTION RECORD
" F North Carolina Department of Environment and Natural Resources-Division of Water Quality
"Q. WELL CONTRACTOR CERTIFICATION# 2669 220122
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 34
KENNETH JORDAN g. WATER ZONES(depth):
Well Contractor(Individual)Name From 94 To 102 From 201 To 204
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/
Depth Diameter Weight Material
BOONE NC 28607 From 0 To 94 Ft. 6 1/4 188 (;AI V
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
SITE WELL ID#(if applicable)- From 0 To 20 Ft. CEMENT PUMPED
From To -- Ft-25 BAGS-----• — —
WELL CONSTRUCTION PERMIT#163145 From To Ft.
OTHER ASSOCIATED PERMIT#(if applicable) 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply X From To Ft. in. in.
DATE DRILLED 10/5/2022 From To Ft. in. in.
TIME COMPLETED 03:00 AM 0 PM OX From To Ft. in. in.
4.WELL LOCATION: 10.SAND/GRAVEL PACK:
CITY: BOONE COUNTY WATAUGA Depth Size Material
From To Ft.
OFF CURLEY MAPLE OFF HOWARDS CREEK/194 From To _ Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Cade) From To Ft.
TOPOGRAPHIC/LAND SETTING:
0 Slope 0 Valley 0 Flat 0 Ridge 0 Other
(check appropriate box) 11. DRILLING LOG
May be in degrees, From To Formation Description
LATITUDE — _ 36.15641 minutes,seconds or 0 60 RED DIRT BOULDERS GRAY CLAY
LONGITUDE 81A3471 in a decimal format 60 84 _SHALE ROCK GRANITE
— — 84 94 GRANITE
Latitude/longitude source: X GPS 0 Topographic map 94 102 SHALE ROCK
(location of well must be shown on a USGS topo map and 102 201 GRANITE
attached to this form ifnot using GPS) 201 204 FLINT WHITE QUARTZ
204 220 GRANITE
5.WELL OWNER
OWNER'S NAME DEBRA ROGAN
STREET ADDRESS 6913 BROOK RIDGE COURT C M
RALEIGH NC 27615
City or Town State Zip Code n r T 1 2d22
(215 )_ 859-8396
Area code- Phone number 12. REMARKS: In cr17�:=`cn+�r, .'_��"J Ira
2 GPM 94-102 28GPM 201-204 C�4J0iJ"
6.WELL DETAILS:
a. TOTAL DEPTH: 220
b. DOES WELL REPLACE EXISTING WELL? YES 0 NOX 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: 20 FT. RECORD BEEN 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 attor below land surface may require SI OF CERTIFIED WELL CONTRACTOR DATE
a variance in accordance with 15A NCAC 2C.0118. KENNETH JORDAN
e. YIELD(gpm): 30 METHOD OF TEST AIR PRINTED NAME OF PERSON CONSTRUCTING THE WELL
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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 668. Rev.3/07

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