GW1--05192_Well Construction - GW1_20230814

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'k r . RESIDENTIAL WELL CONSTRUCTION RECORD
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„' 1, North Carolina Department of Environment and Natural Resources-Division o�'Water Quality
WELL CONTRACTOR CERTIFICATION# 3867 230107,
1.WELL CONTRACTOR: f, DISINFECTION:Type HTH Amount 113
RANDALL MAIN g. WATER ZONES(depth):
Well Contractor(Individual)Name • From 680 To 682 . 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 Ft.
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 Ft. _
SITE WELL ID#(if applicable) From To- Ft:
WELL CONSTRUCTION PERMIT# 129997 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 7/31/2023 From To Ft. in. in.
TIME COMPLETED 0300 AM[1 PM uX From To Ft. in. in.
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4.WELL LOCATION: • 10.SAND/GRAVEL PACK:•
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CITY: DRILL DEEPER COUNTY WATAUGA Depth Size Material
From To Ft.
167 WAGON WHEEL OFF COUNTRY RD OFF MTN From To 'Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) From To Ft.
TOPOGRAPHIC/LAND SETTING: ,
o Slope 0 Valley 0 Flat 0 Ridge 0 Other
(check appropriate box) 11. DRILLING LOG
May be in degrees, From To Formation Description
LATITUDE _ 36.191340 minutes,seconds or 0 505 EXISTING WELL
LONGITUDE 81.485200 in a decimal format 505 680 GRFY GRANITE
— — 680 682 GREY GRANITE
Latitude/longitude source: X GPS o Topographic map 682 750 BLACK GRANITE
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
5.WELL OWNER " r�® . F; �.
OWNER'S NAME
JOSE MENDEZ • �'�- i k. R....L"
STREET ADDRESS 197 WAGON WHEEL LN AUG jI ,; zoz
DEEP GAP NC 28618
City or Town State - Zip Code • Ir.-`'::^-'='ds t ?r-•^�7,.:,::,3 Urtk
( 828 )_ 386-5286 D1:`fQ/30i,;
Area code- Phone number 12. REMARKS: '
15 GPM 680-682
6.WELL DETAILS:
a. TOTAL DEPTH: 750
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: 200 FT. RECORD H S BEEN PROVIDED TO THE WELL OW4IER.
(Use"+"if Above Top of Casing) Aia
,yd. TOP OF CASING IS 1 FT.Above Land Surface* ' ' 5-1.- 2
*Top of casing terminated at/or below land surface may require SIG ATURE OF CERTIFIED WELL CONTRACTOR DATE
a variance in accordance with 15A NCAC 2C.0118. RANDALL MAIN
e. YIELD(gpm): 15 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-1a
1617 Mail Service Center—Raleigh, NC 27699-1617 Phone No.[phone] ext 568. Rev.3/07

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