GW1-2023-02109_Well Construction - GW1_20230303

• Y. a ,• RESIDENTIAL WELL CONSTRUCTION RECORD
b ,g North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 2669 220189
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 109
KENNETH JORDAN g. WATER ZONES(depth):
Well Contractor(Individual)Name
From 380 To 400 From 530 To 531
' DEWEY WRIGHT WELL&PUMP CO., INC From 560 To 575 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 120 Ft. 6 VI 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
From 0 To 20 _Ft. BENTONIT GRAVITY __ __ _ _
---- -- - --SITE-WELL--ID#(if-applicable) — — From To Ft. 17 BAGS
WELL CONSTRUCTION PERMIT#328403 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 2/20/2023 From To Ft. in. in.
TIME COMPLETED 0300 AM 0 PM OX From To Ft. in. in.
4.WELL LOCATION: 10.SAND/GRAVEL PACK:
CITY: FLEETWOOD COUNTY ASHE Depth Size Material
From To Ft.
EAGLE DR OFF LAKEFRONT DR OFF CREEKSIDE From To Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) From To Ft.
TOPOGRAPHIC/LAND SETTING:
0 Slope O Valley X Flat 0 Ridge 0 Other 11. DRILLING LOG
(check appropriate box)
May be in degrees, From To Formation Description
LATITUDE _ _ 36.28148N minutes,seconds or 0 106 DIRT
LONGITUDE 81.51119W in a decimal format 106 190 - GRANITE
— — - 190 210 SHALE
Latitude/longitude source: Xi GPS 0 Topographic map 210 360 GRANITE
(location of well must be shown on a USGS topo map and 360 380 SHALE
attached to this form if not using GPS) 380 400 GRANITE t' .-1Ar}{ MIX;
5.WELL OWNER 400 530 GRANITE
530 531 VOID ;`t 7-' (1j``-'
OWNER'S NAME ROBERT ROTEN _531 560 GRANITE - .. -,i:_.^G,..._', V '!—, --•.I
STREET ADDRESS PO BOX 25 560 575 QUARTZ
575 605 GRANITE MAR ) S 2023
LANSING NC 28643
City or Town State Zip Code 10 7;-;-,._- yy�,.! .�, - ,.,,.',-..g kJI�(�.
•
(828 )_ 773-0995 ,_;V. r.-)u1;.=
Area code- Phone number 12. REMARKS:
5 GPM 380-400
6.WELL DETAILS: 10 GPM 530 531
a. TOTAL DEPTH: 605 5 GPM 560 575
b. DOES WELL REPLACE EXISTING WELL? YES 0 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: 80 FT. RECORD HA BEEN P VIDED TO THE W L OWNER.
(Use"+"if Above Top of Casing) C��yr/�� L'�G�
d. TOP OF CASING IS 1 FT.Above Land Surface* 77 r?�(7`a`'- ?
*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): 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: Information Mgt., Form GW-la
1617 Mail Service Center—Raleigh, NC 27699-1617 Phone No.[phone] ext 568. Rev.3/07

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