GW1--05193_Well Construction - GW1_20230814

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�.;�.� �, �. -', RESIDENTIAL WELL CONSTRUCTION REORD
6 ;:, a" North Carolina Department of Environment and Natural Resources-Division of Water Quality
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,,r:.:,_': i' WELL CONTRACTOR CERTIFICATION# 3867 220200
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount
RANDALL MAIN g. WATER ZONES(depth):
Well Contractor(Individual)Name From 120 To 121 From 260 To 261
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 55 Ft. 6 1/4 188 GAI V
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
SITE WELL ID#(ifapplicable) From 0 To 20 Ft. BENTONIT GRAVITY "
- - - — — — — —_ — From To-- —
.3 Ft2 BAGS- -
WELL CONSTRUCTION PERMIT# 167078 From To Ft. 1
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 8/3/2023 From To Ft.1 in. in.
TIME COMPLETED 0300 AM 0 PM OX From To Ft. in. in.
4.WELL LOCATION: 10.SAND/GRAVEL PACK:
CITY: TODD COUNTY WATAUGA Depth Size Material
From To Ft.
OFF GRACE MTN OFF HWY 194 OFF HWY 421S 0 From To Ft.1
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) From To Ft.1 _
) TOPOGRAPHIC/LAND SETTING:
II Slope 0 Valley 0 Flat 0 Ridge 0 Other 11. DRILLING LOG
(check appropriate box)
May be in degrees, From To , Formation Description
LATITUDE — — 36.09304 minutes,seconds or 0 59 DIRT I
LONGITUDE 81.44964 in a decimal format 59 120 GRFY GRANITE
— — 120 _ 121 VAIN I
Latitude/longitude source: X GPS o Topographic map 121 260 GRANITE!
(location of well must be shown on a USGS topo map and 260 261 VAIN I
attached to this form if not using GPS) 261 340 GREY GRANITE
340 400 GRANITE QUARTZ
5.WELL OWNER I
OWNER'S NAME GARY&ELLEN BLAIS C/O TIMBER S --
STREET ADDRESS PO BOX 1597 -. " ...i . . p
BOONE NC 28607 AUG 1 ��13
City or Town State Zip Code
( 828 )- 964-3802
Area code- Phone numberIr f 7=^s^.,t Pr4 c F4 i.hl
12. REMARKS: Dtw�OWY1
2 GPM 120-121
6.WELL DETAILS: • 1.1 GPM 260-261
a. TOTAL DEPTH: 400
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: FT. RECO HAS B N OVIDED TO THE WELL OWNER.
(Use"+"if Above Top of Casing) i�(,/�.M"., g�rl�3
d. TOP OF CASING IS 1 FT.Above Land Surface*
*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): 3.1 METHOD OF TEST AIR PRINTED NAME OF PERSON CONSTRUCTING THE WELL
II
I
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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