GW1-2023-02932_Well Construction - GW1_20230420

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1.c'ei RESIDENTIAL WELL CONSTRUCTION RECORD
v;5-ri j �'A' North Carolina Department of Environment and Natural Resources-Division of Water Quality
°° ° .- WELL CONTRACTOR CERTIFICATION# 2669 230040
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 139
KENNETH JORDAN g. WATER ZONES(depth):
Well Contractor(Individual)Name From 420 To 450 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 90 Ft. R 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
SITE WELL ID#(if applicable) ---- -- - From 0 - To 20 - Ft.-BENTONIT— GRAVITY - -- -
From To Ft. 18 BAGS
WELL CONSTRUCTION PERMIT# 126269 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 4/10/2023 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 Material
From To Ft.
244 BEAVER CREEK ESTATE WAY OFF BEAVER( From To Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) From To Ft.
TOPOGRAPHIC/LAND SETTING:
0 Slope 0 Valley X Flat 0 Ridge 0 Other_ 11. DRILLING LOG
(check appropriate box)
May be in degrees, From To Formation Description
LATITUDE _ 36.35274N minutes,seconds or 0 79 DIRT
LONGITUDE 81.51700W in a decimal format 79 130 GRANITE
— — 130 250 SHALE
Latitude/longitude source: X GPS n Topographic map 250 380 GRANITE
(location of well must be shown on a USGS topo map and 380 420 SHALE
attached to this form if not using GPS) 420 450 GRANITE QUARTZ
450 520 GRANITE
5.WELL OWNER
GRANITE
OWNER'S NAME
HEATHER&ANDREW HERMAN 600 640 SHALE
STREET ADDRESS PO BOX 278 640 805 GRANITE -_c-
JEFFERSON NC 28640
City or Town State Zip Code APR 2 0 ?LLU
(336 )- 977-2943
Area code- Phone number 12. REMARKS: .• • -
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.5 GPM 420-450 }D!,'J:1J50G
6.WELL DETAILS:
a. TOTAL DEPTH: 805
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 HAS BEEN PROVIDED T THE WELL OWNER.
(Use"+"if Above Top of Casing) /��
d. TOP OF CASING IS 1 FT.Above Land Surface* �� �_ / 7 T-p
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*Top of casing terminated at/or below land surface may require
SIGNATURE RTIFIED WELL CONTRACTOR DATE
a variance in accordance with 15A NCAC 2C.0118. KENNETH JORDAN
e. YIELD(gpm): .5 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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