GW1--03352_Well Construction - GW1_20230512

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�� RESIDENTIAL WELL CONSTRUCTION RECORD
"' : ,g' North Carolina Department of Environment and Natural Resources-Division of Water Quality
'°`.`°V'' WELL CONTRACTOR CERTIFICATION# 2669 230045
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 124
KENNETH JORDAN g. WATER ZONES(depth):
Well Contractor(Individual)Name
From 630 To 632 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 100 Ft. 6 1/E 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#367117 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 5/1/2023 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: SUGAR GROVE COUNTY WATAUGA Depth Size Material
From To Ft.
OFF JACOBS POND OFF ROMINGER OFF WATAU 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 — 36.23342N minutes,seconds or 0 89 DIRT
LONGITUDE 81.82257W in a decimal format 89 168 GRANITF
— — 168 180 GRANITE RED GRANITE
Latitude/longitude source: X GPS a Topographic map 180 310 GRANITE . --- .''.;--- Y 1.--;"
310 340 . SHALE lr;''j i i" r• ;d L,.
(location of well must be shown on a USES topo map and L e
attached to this form if not using GPS) 340 510 GRANITE510 560 SHALE
1t
5.WELL OWNER 560 630 GRANITE MAY 1 2 2Q23
OWNER'S NAME DYLAN SMITH C/O MIKE SMITH 630 632 VOID - IJr,t
GRANITE ,;'r;_:
STREET ADDRESS 243 JACOBS POND RD 632 705 t�_ r• T5
1ti
SUGAR GROVE NC 28679
City or Town State Zip Code
(828 )_ 244-6068
Area code- Phone number 12. REMARKS:
6 GPM 630-632
6.WELL DETAILS:
a. TOTAL DEPTH: 705
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 H S BEEN PROVIDED TO THE WELL OWNER.
(Use"+"if Above Top of Casing)
d. TOP OF CASING IS 1 FT.Above Land Surface' cf"a- a
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): 6 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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