GW1-2022-09560_Well Construction - GW1_20221021

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r� RESIDENTIAL WELL CONSTRUCTION RECORD
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t A North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 2669
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 46
KENNETH JORDAN g. WATER ZONES(depth):
Well Contractor(Individual)Name From 138 To 143 _ From 190 To 193
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 To 191 Ft. R 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-#(ifapplicable)- - - From- _ To Ft:30-B-AGS--— -----=-,-- _
WELL CONSTRUCTION PERMIT# 184297 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 10/7/2022 From To Ft. in. in.
TIME COMPLETED 0300 AMR PM OX From To Ft. in. in.
4.WELL LOCATION: 10.SAND/GRAVEL PACK:
CITY: BOONE COUNTY WATAUGA Depth Size Material
From To Ft.
N.WOODS DR/JUNALUSKA/EASTVIEW/KING ST 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 0 121 RED DIRT GRAVEL GRANITE
LONGITUDE in a decimal format 121 138 GRANITE
— — 138 143 FLINT
Latitude/longitude source: a GPS a Topographic map 143 190 GRANITE
(location of well must be shown on a USGS topo map and 190 193 FLINT WHITE QUARTZ
attached to this form if not using GPS) 193 300 GRANITE
5.WELL OWNER E
iT"�•� �P"�EVE
OWNER'S NAME VON FORDHAM ?:_:, , : ie
STREET ADDRESS 220 EAST BOUNDARY ST _ OCT nl �n��
CHAPIN SC 29036 [02e
City or Town State Zip Code ,.
(803 )_ 760-0114 IniCrillH:...'1 � n:_,•s�:,�Urm
GWIDiB Ora
Area code- Phone number 12. REMARKS:
10 GPM 138-143 10 GPM 190-193
6.WELL DETAILS:
a. TOTAL DEPTH: 300
b. DOES WELL REPLACE EXISTING WELL? YES 0 N0 a 1 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: 76 FT. RECORD HAS BEEN PROVI E O 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 RTIFIED WELL CONTRACTOR DATE
a variance in accordance with 15A NCAC 2C.0118. KENNE JORDAN
e. YIELD(gpm): 20 METHOD OF TEST AIR PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn:I rmation Mgt., Form GW-1a
1617 Mail Service Center-Raleigh,NC 27699-1617 Phone No.[phone] ext 568. Rev.3/07

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