GW1-2023-02474_Well Construction - GW1_20230404

- ..a.STATE . '
f Y. - %, RESIDENTIAL WELL CONSTRUCTION RECORD
,g North Carolina Department of Environment and Natural Resources-Division of Water Quality
. WELL CONTRACTOR CERTIFICATION# 2669 2201117 • •
1.WELL CONTRACTOR: f. DISINFECTION:Type KITH Amount 54
KENNETH JORDAN g. WATER ZONES(depth): •
Well Contractor(Individual)Name From 180 To 200 From 260 To 261
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 120 Ft. 6 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
SITE WELL ID#(ifapplicable) From 0 To 20 Ft. BENTONIT GRAVITY
From To -- Ft. 20 BAGS- - -- --- - - --
WELL CONSTRUCTION PERMIT#365835 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 3/21/2023 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: LAUREL SPRINGS COUNTY ASHE Depth Size I Material
From To Ft. r-_". :.-- .. _
W OFF FARMVIEW OFF BIG PEAK CR OFF HY 88 I From To Ft. '.,a: E i' ".;''_ `)
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code)
From To Ft.
• TOPOGRAPHIC/LAND SETTING: APR V l 2023
X Slope 0 Valley 0 Flat 0 Ridge 0 Other 11. DRILLING LOG
(check appropriate box) iri C• ;;:: ; TI ;' ; ,,.;. ,.
May be in degrees, From To FormatioUl tlDecripfioli'_J l
LATITUDE — — 36.40151N minutes,seconds or 0 110 DIRT '"Jam'
LONGITUDE 81.30608W in a decimal format 110 180 GRANITE
— — 180 200 QUARTZ
Latitude/longitude source: X GPS o Topographic map 200 260 GRANITE
(location of well must be shown on a USGS topo map and 260 261 VOID
attached to this form if not using GPS) 261 320 GRANITE
5.WELL OWNER
OWNER'S NAME CYNTHIS LEWIS
• STREET ADDRESS 5663 NC HWY 88 W
WARRENSVILLE NC 28693
City or Town State Zip Code
(336 )- 977-2796
Area code- Phone number 12. REMARKS:
2 GPM 180-200
6.WELL DETAILS: 10 GPM 260-261
a. TOTAL DEPTH: 320 -
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: 60 FT. RECORD HAS B N PROVIDED TO THE WELL OWNER.
(Use"+"if Above Top of Casing) Y`a y (-
d. TOP OF CASING IS 1 FT.Above Land Surface* ( J
*Top of casing terminated at/or below land surface may require SIGNATURE OF CER ED WELL CONTRACTOR DATE
a variance in accordance with 15A NCAC 2C.0118. KENNETH JORDAN
e. YIELD(gpm): 12 METHOD OF TEST AIR PRINTED NAME OF PERSON CONSTRUCTING THE WELL
•
' I
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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