GW1-2023-02478_Well Construction - GW1_20230404

r` �t;f. RESIDENTIAL WELL CONSTRUCTION RECORD
}g North Carolina Department of Environment and Natural Resources-Division of Water Quality
„h, ', WELL CONTRACTOR CERTIFICATION# 2669 22Q007
•
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 54
KENNETH JORDAN g. WATER ZONES(depth): •
Well Contractor(Individual)Name From 265 To 275 From To ..
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 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#(if applicable)
- From - To Ft.-20_BAGS------ - — - --- -
WELL CONSTRUCTION PERMIT#356906 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 3/23/2023 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: WEST JEFFERSON COUNTY ASHE Depth Size.. ti!`tfMaterial,v:?,7 "3
From To Ft. 4r
LOT#8&9 OFF WALDEN RD OFF CALLOWAY RC From To Ft. rr -
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) From To Ft. H' " - L3
TOPOGRAPHIC/LAND SETTING: ln;,-.. ;;, 2:l 'rr.c' ..;=;J Ur,i
0 Slope 0 Valley 0 Flat 0 Ridge 0 Other D ;5,y:.
(check appropriate box) 11.DRILLING LOG
May be in degrees, From To Formation Description
LATITUDE — 36.302169 minutes,seconds or 0 70 DIRT
LONGITUDE 81.382856 in a decimal format 70 190 GRANITE
— — 190 210 SHALE
Latitude/longitude source: )4 GPS o Topographic map 210 265 GRANITE
(location of well must be shown on a USGS topo map and 265 275 QUARTZ
attached to this form if not using GPS) 275 320 GRANITE
5.WELL OWNER 1
• OWNER'S NAME MARTHA CURD
STREET ADDRESS 3345 GRANDVIEW CLUB RD
PFAFFTOWN NC 27040
City or Town State • Zip Code
(828 )- 457-2444
Area code- Phone number 12. REMARKS:
• 12 GPM 265-275
6.WELL DETAILS: •
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 BEEN PROVIDED TO THE WELL OWNER.
(Use"+"if Above Top of Casing) L(
d. TOP OF CASING IS 1 FT.Above Land Surface* ra,J pl.)
*Top of casing terminated at/or below land surface may require SIGN OF CERTIFIED 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
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. Rev.3/07

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