GW1-2023-02240_Well Construction - GW1_20230307

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STA G. -
- % RESIDENTIAL WELL CONSTRUCTION RECORD
QNorth Carolina Department of Environment and Natural Resources-Division iofWater Quality
�d; ` " WELL CONTRACTOR CERTIFICATION# 2669 220173
4.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 54
KENNETH JORDAN
Well Contractor(Individual)Name g. WATER ZONES(depth):
From 175 To 182 From 248 To 249
DEWEY WRIGHT WELL&PUMP CO., INC From 280 To 290' 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 n To 80 Ft. 6 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
_ From 0 To 20 Ft. BENTONIT GRAVITY _.___ _
- -- .SITE-WELL ID#(ifapplicable)'-= - �_ F-
rom__ To Ft. 18 BAGS
WELL CONSTRUCTION PERMIT#361440 From To Ft.
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 2/16/2023 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: BOONE COUNTY WATAUGA Depth Size Material
From To Ft.
HWY 194 OFF 421 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 — — 36.28072N minutes,seconds or 0 70 DIRT
LONGITUDE 81.64900W in a decimal format 70 175 GRANITE
— — 175 182 QUARTZ
Latitude/longitude source: X GPS 0 Topographic map 182 248 GRANITE
(location of well must be shown on a USGS topo map and 248 249 VOID
attached to this form if not using GPS) 249 280 GRANITE
280 290 QUARTZ
5.WELL OWNER 290 325 GRANITE
OWNER'S NAME JUSTIN DAVIS
STREET ADDRESS 2013 CHESTERFIELD AVE I' __ "
CHARLOTTE NC 28205 3
City or Town State Zip Code MAP,�i , I" Lc Z�J
(828 )_ 964-1993
Area code- Phone number 12. REMARKS: IT:'::•:C..
5 GPM 175-182
6.WELL DETAILS: 3 GPM 248-249
a. TOTAL DEPTH: 325 27 GPM 280 290
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO 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: 60 FT. RECORD HAS B N PROVIDED TO THE WELL OWNER.
(Use"+"if Above Top of Casing)
d. TOP OF CASING IS 1 FT.Above Land Surface' --e- fir- Coe.?
*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): 35 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-1 a
1617 Mail Service Center—Raleigh,NC 27699-1617 Phone No.[phone] ext 568. I 1 Rev.3/07

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