GW1-2022-00340_Well Construction - GW1_20221222

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f'( M RESIDENTIAL WELL CONSTRUCTION RECORD
gNorth Carolina Department of Environment and Natural Resources-Division of Water Quality
' WELL CONTRACTOR CERTIFICATION# 2669 220163
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1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 66
KENNETHJORDAN g. WATER ZONES(depth): '
Well Contractor(Individual)Name From 195 To 200 From 270 To 275
DEWEY WRIGHT WELL&PUMP CO., INC From 350 To 355 From To
Well Contractor Company Name From To From To
STREET ADDRESS PO BOX 308 7. CASING: Thickness/
BOONE NC 28607 From Depth Diameter Weight Material
� To 80 Ft. F 1/A _ixin PVr
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. 32 BAGS
WELL CONSTRUCTION PERMIT#369160 From To I�Fi.
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 12/2/2022 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.
194 SIERRA VISTA OFF DECK HILL OFF WINKLER 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)
LATITUDE _ 36.19129N May be in degrees, From To Formation Description
minutes,seconds or 0 65 DIRT i
81.67115N in a decimal format 65 195 GRANITE
LONGITUDE_ _ 195 200 QUARTZ
Latitude/longitude source: o GPS 0 Topographic map 200 270 GRANITE
(location of well must be shown on a USGS topo map and 270 275 QUARTZ GRANITE
attached to this form ifnot using GPS) 275 350 GRANITE
350 355 QUARTZ
S.WELL OWNER 355 400 GRANITE .
OWNER'S NAME JASON MATTHEWS
STREET ADDRESS 655 WINKLERS CREEK RD
BOONE NC 28607 '
City or Town State Zip Code
(828 )_ 406-1391
Area code- Phone number 12. REMARKS:
4 GPM 195-200
6.WELL DETAILS: 2 GPM 270-275
a. TOTAL DEPTH: 400 2 GPM 350-355
b. DOES WELL REPLACE EXISTING WELL? YES 0 NODC 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: 80 FT. RECORD HAS BEEN PROVIDED TO THE WELL OWNER..
(Use"+"if Above Top of Casing) i
d. TOP OF CASING IS 1 FT.Above Land Surface*
*Top of casing terminated atior below land surface may require SIGNATURE OF FIED IWi LL CONTRACTOR DATE
a variance in accordance with 15A NCAC 2C.0118. KENNETH JORDAN
e. YIELD(gpm): 8 METHOD OF TEST AIR PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn:Information Mgt., Form GWA a
1617 Mail Service Center—Raleigh,NC 27699-1617 Phone No.[phone] ext 668. Rev.3/07

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