GW1-2023-00583_Well Construction - GW1_20230109

I '
Ii
. '. RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality WELL CONTRACTOR CERTIFICATION# 2669 210227
1.WELL CONTRACTOR: f. DISINFECTION:Type!HTH Amount 71
KENNETH JORDAN g. WATER ZONES(depth)-
Well Contractor(Individual)Name From 62 To 70 From 290 To 340
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
_0_To 40 Ft.R 1/R .1450 Pylr
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 J Ft. 20 BAGS
WELL CONSTRUCTION PERMIT#355680 From To Ft.
OTHER ASSOCIATED PERMIT#(if applicable)
9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply 0 From To Ft. in. in.
DATE DRILLED 1/4/2023 From To Ft. in. in.
TIME COMPLETED 0300 AMU PM OX From To Ft. in. in.
4.WELL LOCATION: 10.SAND/GRAVEL PACK:
CITY: VILAS COUNTY WATAUGA Depth. Size Material
From To Ft.
OFF.BEAVER DAM RD OFF BULLDOG RD OFF HIA From To Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) From ••To Ft.
TOPOGRAPHIC%LAND SETTING
0 Slope 11 Valley q Flat 0 Ridge II Other 11.DRILLING LOG
(check"appropriate box)
May be in degrees, From To Formation Description
LATITUDE _— 36.342002 minutes,--seconds or 0 30 - RED DIRT SHALE ROCK
LONGITUDE 81.799432 in a decimal format 30 62 GRANITE
— — 62 70 BROWN SHALE GRANITE
Latitude/longitude source: X GPS 0 Topographic map 70 290 GRANITE PINK S .T-E— ^ ,7.
(location of well must be shown on a USGS topo map and 290 340 PINKS SLATE "
attached to this form if not using GPS) 340 400 GRANITE PINK SLATE nq
S.WELL OWNER I�� Iva
OWNER'S NAME PETER RAPOL I
STREET ADDRESS 3855 CHANDERVILLE RD D`ati, `yL
ZANESVILLE OH 43701
City or Town State Zip Code
(740 )_ 819-3302
Area code- Phone number 12. REMARKS:
1 GPM 62-70
6.WELL DETAILS: 2 GPM 290-340
a. TOTAL DEPTH: 400
b. DOES WELL REPLACE EXISTING WELL? YES 9 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: 50 FT. RECORD HAS EN PROYHD EDT THEW L OWNER.
(Use'Y'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 TIFIED'WELL CONTRACTOR DATE
` a variance in accordance with 15A NCAC 2C.0118. KENNETH JORDAN I- j - -
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:Information Mgt., Form GWAa
1617 Mail Service Center—Raleigh,NC 27699-1617 Phone No.[phone] ext 568. Rev.3107
f

r R-
c' r