GW1-2022-09558_Well Construction - GW1_20221021

. RESIDENTIAL WELL CONSTRUCTION RECORD
ft ag,' North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 2669 220040
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 87
KENNETHJORDAN g. WATER ZONES(depth):
Well Contractor(Individual)Name
From 35 To 40 From 67 To 73
DEWEY WRIGHT WELL&PUMP CO., INC From 347 To 353
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 To-2 _Ft. F, 1/R 350 _ PVC
City or Town State Zip Code From 2 To 23 Ft. 6 1/4 .188 GALV
8( 28 )-264-2651 From To Ft.
Area code- Phone number
2.WELL INFORMATION: 8. GROUT: Depth Material Method
From 0 To 20 Ft. CEMENT PUMPED
SITE WELL ID#(ifapplicable) From To "Ft.-49-BAGS--
WELL CONSTRUCTION PERMIT#335399 From To Ft.
OTHER ASSOCIATED PERMIT#(if applicable) 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply IX From To Ft. in. in.
DATE DRILLED 09/27/2022 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 STONY BROOK LN OFF HOWARDS CREEK/1! 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 11. DRILLING LOG
(check appropriate box)
May be in degrees, From TO Formation Description
LATITUDE — — 36.24095N minutes,seconds or 0 4 BROWN DIRT
LONGITUDE 81.66358W in a decimal format 4 15 GRAVEL BOULDERS
— — 15 35 GRANITE
Latitude/longitude source: X GPS u Topographic map 35 40 BROWN SHALE
(location of well must be shown on a USGS topo map and 40 67 GRANITE
attached to this form if not using GPS) 67 73 FLINT,QUARTZ
5 73 347 GRANITE
.WELL OWNER
347 353 FLINT,WHITE QUARTZ
OWNER'S NAME WILL&ERIN SELLE 353 420 GRANITE r- + "? 0
STREET ADDRESS 618 TIMBER LN DR `"-
t,aP.
BOONE NC 28607 T ? 2022
City or Town State Zip Code
(828 )_ 577-1123
Area code- Phone number 12. REMARKS•
8.WELL DETAILS: 1 GPM 35-40 1 GPM 67-73 1 GPM 347-353
a. TOTAL DEPTH: 420
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: 2 FT. RECORD HAS PEN PROVIDED T THE WELL OWNER.
(Use"+"if Above Top of Casing)
d. TOP OF CASING IS 1 FT.Above Land Surface*
*Top of casing terminated at/or below land surface may require SIGNATURE OF IFIED WELL CONTRACTOR DATE
a variance in accordance with 15A NCAC 2C.0118. KENNETH JORDAN
e. YIELD(gpm): 3 METHOD OF TEST AIR PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn. ormation Mgt., Form GW-ia
1617 Mail Service Center-Raleigh,NC 27699-1617 Phone No.(919)733-70 ext 568. Rev.3/07

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