GW1--03225_Well Construction - GW1_20230511

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,tirf' � �.._.:z RESIDENTIAL WELL CONSTRUCTION RECORD
3 r g! North Carolina Department of Environment and Natural Resources-Division of Water Quality
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. WELL CONTRACTOR CERTIFICATION# 2669 230058
I.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 89
•
KENNETH JORDAN g. WATER ZONES(depth):
Well Contractor(Individual)Name
From 220 To 240 From 460 To 470
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 8(1 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. 19 BAGS
WELL CONSTRUCTION PERMIT#380890 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 5/4/2023 From To Ft. in. in.
TIME COMPLETED 0300 AM 0 PM IX From_ To Ft. in. in.
4.WELL LOCATION: 10.SAND/GRAVEL PACK:
CITY: TODD • COUNTY ASHE Depth Size Material
From To Ft.
OFF GRANT HOUCK OFF HWY 194S OFF 221 OFF 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 — — 36.337838 minutes,seconds or 0 69 DIRT
LONGITUDE 81.535536 in a decimal format 69 180 GRANITE
— — 180 220 SHALE
Latitude/longitude source: )4 GPS 0 Topographic map 220 240 QUARTZ GRANITE MIX
(location of well must be shown on a USGS topo map and 240 380 GRANITE
attached to this form if not using GPS) 380 420 SHALE
420 460 GRANITE
5.WELL OWNER 460 470 QUARTZ
OWNER'S NAME JEFF GRUBB 470 505 GRANITE _
STREET ADDRESS 939 NC HWY 194S % ` &_� ' ''gI—i
TODD NC 28684 '
City or Town State Zip Code NiAY j023
(336 )_ 977-0250
Area code- Phone number ttlki-rra:icn Pm^t:Y :�g Un!,
12. REMARKS: DkV013 G
1 GPM 220-240
6.WELL DETAILS:
3 GPM 460-470
a. TOTAL DEPTH: 505
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: 70 FT. RECORD HAS BEEN PR VIDED TO THE W LL OWNER.
(Use"+"if Above Top of Casing)
%'
d. TOP OF CASING IS 1 FT.Above Land Surface* G ✓�—�3
*Top of casing terminated at/or below land surface may require SIGNATU OF ERTIFIED WELL CONTRACTOR DATE
a variance in accordance with 15A NCAC 2C.0118. KEN[\ ORDAN
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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