GW1-2022-10197_Well Construction - GW1_20221111

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. RE.S'IDENTML WELL CONSTRUCTION RECORD
" North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 2669 210023
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 90
KENNETH JORDAN g. WATER ZONES(depthj:
Well Contractor(Individual)Name From 375 To 380 From 475 To 480
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 91 Ft. R 114 188 CAI 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
From 0 To 20 Ft. BENTONIT GRAVITY
SITE WELL ID*(if applicable) From To ft. 17 BAGS
WELL CONSTRUCTION PERMIT# 10849 From To Ft.
OTHER ASSOCIATED PERMIT#(if applicable)
9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply ID( From To Ft. in. in.
DATE DRILLED 11/1/2022 From To Ft. in. in.
TIME COMPLETED 0300 AM II PM OX From To Ft. in. in.
4.WELL LOCATION: 10.SAND/GRAVEL PACK:
CITY: BAKERSVILLE COUNTY MITCHELL Depth Size Material
From To Ft.
270 GRACE RIDGE RD BAKERSVILLE NC 28705 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 — — 36.1375N minutes,seconds or 0 8 BROWN RED DIRT
LONGITUDE 081.50483W in a decimal format 8 375 GRANITE
— — 375 380 WHITE!BLUE QUARTZ
Latitude/longitude source: A GPS fl Topographic map 380 475 GRANITE
(location of well must be shown on a USGS topo map and 475 480 FLINT WHITE QUARTZ
attached to this form if not using GPS) 480 600 GRANITE
5.WELL OWNER
OWNER'S NAME ALEX&CYNTHIA STONE
STREET ADDRESS 343 PALMETTO ST NOV 1
MAITLAND FL 32751 IijbiwWw nk
City or Town State Zip Code
(407 )- 462-8955
Area code- Phone number 12. REMARKS:
1 GPM 375-380
6.WELL DETAILS: 1 GPM 475-480
a. TOTAL DEPTH: 600
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO➢C I DO HEREEY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
c. WATER LEVEL Below Top of Casing: 160 FT.
15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
RECORD HAS TO THE WELL OWNER.
(Use"+"if Above Top of Casing)d. TOP OF CASING IS 1 FT.Above Land Surface- !`J �r -%;Z
'Top of casing terminated aUor below land surface may require SIGNATURE CERTIFIED WELL CONTRACTOR DATE
a variance in accordance with 15A NCAC 2C.0118. KENNETH JORDAN
e. YIELD(gpm): 2 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 568. f Rev.3/07
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