GW1-2023-02473_Well Construction - GW1_20230404

. '. RESIDENTIAL WELL CONSTRUCTION RECORD
-t o; North Carolina Department of Environment and Natural Resources-Division of Water Quality
W ' ,,, '�} 2669 220208
^ WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 109
. KENNETH JORDAN g. WATER ZONES(depth):
• Well Contractor(Individual)Name From 220 To 230 From 510 To 575
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/ .
Depth Diameter Weight Material
BOONE NC 28607 From 0 To 73 Ft. A 1/R 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.-18 BAGS- --- ---—---- -
WELL CONSTRUCTION PERMIT#363466 From To Ft.
OTHER ASSOCIATED PERMIT#(if applicable)
9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply D From To Ft. in. in.
DATE DRILLED 3/23/2023 From To Ft. in. in.
TIME COMPLETED 0300 AMU PM OX From To Ft. in. in.
4.WELL LOCATION: 10.SAND/GRAVEL PACK: •
CITY: JEFFERSON COUNTY ASHE Depth Size Material
From To Ft.
LOT#7 OFF WOODLAND SHORES OFF COX RD 01 From To Ft. • `=-+ ,,,,_., •...°'i--i '1
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) From To Ft. LL
TOPOGRAPHIC/LAND SETTING: APR v f ZUZ3
0 Slope 0 Valley 0 Flat 0 Ridge 0 Other
11. DRILLING LOG
(check appropriate box) In«• a:l;z tl :P;;^?,-• J 1.,
� Ir;i
May be in degrees, From To Formation Des�ription
LATITUDE — _ 36.38280N minutes,seconds or 0 1 DIRT
LONGITUDE 81.40800W in a decimal format 1 220 GRANITE
— — 220 230 QUARTZ
Latitude/longitude source: X GPS 0 Topographic map 230 300 GRANITE
(location of well must be shown on a USGS topo map and 300 345 SHALE
attached to this form if not using GPS) 345 480 GRANITE
5.WELL OWNER 480 510 SHALE
510 560 GRANITE
. OWNER'S NAME GEOFF MAYNOR 560 575 QUARTZ
STREET ADDRESS 5 WILLETT WAY 575 625 GRANITE
GREENSBORO NC 27408
City or Town State Zip Code
(336 )_ 707-6216
Area code- Phone number 12. REMARKS:
1 GPM 220-230
6.WELL DETAILS: 3 GPM 510-575
a. TOTAL DEPTH: 625
b. DOES WELL REPLACE EXISTING WELL? YES 0 NOX I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C,W LL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
c. WATER LEVEL Below Top of Casing: 100 FT. RECORD HA EN P OVIDED TO THE WELL OWNER.
(Use"+"if Above Top of Casing)
d. TOP OF CASING IS 1 FT.Above Land Surface*
30.07`/
*Top of casing terminated at/or below land surface may require SIGNATURE O RTIFIED WELL CONTRACTOR DATE
a variance in accordance with 15A NCAC 2C.0118. KENNETH JORDAN
e. YIELD(gpm): 4 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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