_Well Construction - GW1_20230310 (69)

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�` t E %' RESIDENTIAL WELL CONSTRUCTION RECORD
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' North Carolina Department of Environment and Natural Resources-Division of Water Quality
-.,4 a,,, WELL CONTRACTOR CERTIFICATION# 2669 220090
• 20090
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1.WELL CONTRACTOR: f. DISINFECTION:Type HTH 'Amount 49
KENNETH JORDAN g. WATER ZONES(depth):
Well Contractor(Individual)Name From 240 To 245 •
From 289 To 290
DEWEY WRIGHT WELL& PUMP CO., INC From To From To
i 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 105 Ft. 5 1/8 350 PVC
City or Town State Zip Code From To Ft. •
(828 )-264-2651 From To Ft.
. Area code- Phone number
2.WELL INFORMATION: 8. GROUT: Depth Material Method
SITE WELL ID#(if applicable) From 0 To 20 Ft. BENTONIT , . GRAVITY
From To Ft. 21 BAGS
WELL CONSTRUCTION PERMIT#367298 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 2/22/2023 From To Ft. in. in.
TIME COMPLETED 0300 AM 0 PM DX From To Ft. in. in.
4.WELL LOCATION: 10.SAND/GRAVEL PACK:
CITY: WEST JEFFERSON COUNTY ASHE Depth Size,,,,,,,� Materials . r�
From To Ft. l :�' =`c .'`.... ', s 3,,...P
OFF BUCK MTN CIRCLE OFF CLARENCE LYALLS From To Ft. `�' "VJ,'"`' `' J '�°
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) From To Ft. MriL j__9_, �ut
TOPOGRAPHIC/LAND SETTING:
Il Slope 0 Valley X Flat 0 Ridge 0 Other :' �
checkappropriate box it DRILLING LOG IRs '"""' ` t`" `�� Un:c
LATITUDE 36.36126N May be in degrees, From To Formation ' s�rlptton
— — minutes,seconds or 0 105 DIRT
LONGITUDE 81.50769W in a decimal format 105 210 GRANITE
— — 210 240 GRANITE
Latitude/longitude source: )G GPS 0 Topographic map 240 245 QUARTZ
(location of well must be shown on a USGS topo map and 245 289 GRANITE
attached to this form if not using GPS) 289 290 VOID;
290 325 GRANITE
5.WELL OWNER I
OWNER'S NAME PETER ORIFICE
STREET ADDRESS 9349 PASEO DE VALENCIA ST
FORTMYERS FL 33908
City or Town State Zip Code
(239 )- 887-0123
Area code- Phone number 12. REMARKS:
8 GPM 240-245
6.WELL DETAILS: •
32 GPM 289-290
a. TOTAL DEPTH: 325
b. DOES WELL REPLACE EXISTING WELL? YES 0 NOX I DO HERESY 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)
d. TOP OF CASING IS 1 FT.Above Land Surface* -3-3-
*Top of casing terminated at/or below land surface may require SIGNATU CERTIFIED WELL CONTRACTOR DATE
a variance in accordance with 15A NCAC 2C.0118. KENNETH JORDAN
e. YIELD(gpm): 40 METHOD OF TEST Al R 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-la
• 1617 Mail Service Center—Raleigh,NC 27699-1617 Phone No.[phone] ext 568. 1 1 Rev.3/07

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