GW1--05022_Well Construction - GW1_20230807

• i
i
'�i ' t • RESIDENTIAL WELL CONSTRUCTION RECORD
5 1 lid, ,Q North Carolina Department of Environment and Natural Resources-Divisionlof
;��{ Water Quality
*:`'4 c,,i.,_•:30?' WELL CONTRACTOR CERTIFICATION# 3867 220174
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 113
RANDALL MAIN g. WATER ZONES(depth):
Well Contractor(Individual)Name
From 700 To 900 , 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 39 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
8. GROUT: Depth Material Method
2.WELL INFORMATION:
From 0 To 20 Ft. BENTONIT GRAVITY
SITE WELL ID#(if applicable) From To 1 Ft. 30 BAGS
WELL CONSTRUCTION PERMIT#364433 From To Ft.
OTHER ASSOCIATED PERMIT#(if applicable)
9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply I From To Ft. in. in.
DATE DRILLED 7/13/2023 • From To 1 Ft. in. in.
TIME COMPLETED 0300 AM O PM OX From To Ft. in. in.
4.WELL LOCATION: - 10.SAND/GRAVEL PACK:
CITY: "BOONE COUNTY WATAUGA •Depth Size Material
From To Ft.
WILSON RIDGE RD OFF DEERFIELD 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 II Flat 0 Ridge 0 Other 11. DRILLING LOG
(check appropriate box)
May be in degrees, From To Formation Description
LATITUDE — 36.20424N minutes,seconds or 0 34 DIRT
LONGITUDE 81.62874W in a decimal format 34 180 GRANITE
— — 180 300 GREY GRANITE.SHALE
Latitude/longitude source: )4 GPS o Topographic map 300 400 BLACK GRANITE
(location of well must be shown on a USGS topo map and 400 440 GRANITE,PINK QUARTZ
• attached to this form if not using GPS) 440 500 GRANITE,SHALE
5.WELL OWNER 500 580 PINK QUARTZ,GREY GRANITE
580 660 SHALE,GRANITE
OWNER'S NAME BEN GREENE 660 900 GRANITE,SHALE ,
STREET ADDRESS 201 CECIL ST _
BOONE NC 28607 • ` ''-.,.:
a"`--�it.. 4�F
City or Town State . Zip Code
( 828 )- 964-1294 D 3
Area code- Phone number 12. REMARKS:
.5 GPM 700-900 IniG:l::: ',..._.;:,:--, `r:.
6.WELL DETAILS: • ,;.,
a. TOTAL DEPTH: 900
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: 350 FT. RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
(Use"+^if Above Top of Casing) , t� /
1.d. TOP OF CASING IS 1 FT.Above Land Surface* �/`/1`���{h�'y .i.1._m
*Top of casing terminated at/or below land surface may require SIGNATURE 0 CERTIFIED WELL CONTRACTOR ATE
a variance in accordance with 15A NCAC 2C.0118. RANDALL MAIN
e. YIELD(gpm): .5 METHOD OF TEST AIR PRINTED NAME OF PERSON CONSTRUCTING THE WELL
II
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. I Rev.3/07

•
Zaat
%AID A'
40y,_
•
i