GW1--04663_Well Construction - GW1_20230721

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P ESIDEai 11191L WELL CONSTRUCTION RECORD
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' tf o; North Carolina Department of Environment and Natural Resources-Division of Water Quality
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' WELL CONTRACTOR CERTIFICATION# 3867 220156
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 55
RANDALL MAIN g. WATER ZONES(depth):
Well Contractor(Individual)Name From 290 To 292 From 300 To 304 ,
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 f) To Ag Ft. A 1/A 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#270432 - From To I Ft. •
OTHER ASSOCIATED PERMIT#(if applicable)
9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply II From To Ft. in. in.
DATE DRILLED 7/6/2023 From To Ft. in. in.
• TIME COMPLETED 0300 AM II PM DX From To Ft. in. in.
4.WELL LOCATION: , 10.SAND/GRAVEL PACK:
CITY: BLOWING ROCK COUNTY WATAUGA Depth Size . Material
From To Ft. •
132 KNOB RD OFF 221S OFF 321 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
(check appropriate box) 11.DRILLING LOG • -
May be in degrees, From To Formation Description
LATITUDE _ _ 36.25528 minutes,seconds or 0 79 DIRT.CONSOLDATED ROCK
LONGITUDE 61.2172g in a decimal format 79 140 GRANITE
— _ 140 220 LIMESTONE.GRANITE
Latitude/longitude source: X•GPS 0 Topographic map 220 290 GRANITE
(location of well must be shown on a USGS topo map and • 290 292 CREVIS
• attached to this form if not using GPS) 292 300 GRANITE
300 304 VOID
5.WELL OWNER 304 320 BLACK GRANITE �^
OWNER'S NAME KEVIN HALL Fi ��
STREET ADDRESS 1860 ADARE DR
• CLEMMONS NC 27012 - JUL 2 1 2023
City or Town State Zip Code lnforir. aon Procark i g 11t...
(336 ')- 813-4760 • - DW BO.
Area code- Phone number 12. REMARKS:
2 GPM 290-292
6.WELL DETAILS: 18 GPM 300-304
a. TOTAL DEPTH: 320
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO •
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: 50 FT. REC HAS BEEN PROVIRED TO THE WELL OWNER.
(Use"+"if Above Top of Casing) / ,1
d. TOP OF CASING IS 1 FT.Above Land Surface* .1. e r - 1-11 -��
*Top of casing terminated at/or below land surface may require SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
a variance in accordance with 15A NCAC 2C.0118. RANDALL MAIN
e. YIELD(gpm): 20 METHOD OF TEST AIR PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Informati In Mgt., Form GW-la
1617 Mail Service Center—Raleigh,NC 27699-1617 Phone No.[phone] ext 568. Rev.3/07

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