GW1--07200_Well Construction - GW1_20231108

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i, r 'I ,. RESIDENTIAL WELL CONSTRUCTION RECORD
6 a' North Carolina Department of Environment and Natural Resources-Division of Water Quality
,,Z,�„.�, WELL CONTRACTOR CERTIFICATION# 3867 22u037
1.WELL CONTRACTOR: f. DISINFECTION:Type IHl H Amount 36
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RANDALL MAIN g. WATER ZONES(depth'):
Well Contractor(Individual)Name From To
From 120 To 121
DEWEY WRIGHT WELL&PUMP CO., INC From To I 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 70 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
2.WELL INFORMATION: 8. GROUT: Depth Material Method
From 0 To 20 Ft. BENTONIT GRAVITY
SITE WELL ID#(if applicable)' From To I I t. 20 BAGS —.
WELL CONSTRUCTION PERMIT# 174172 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 10/31/2023 From To Ft. in. in.
TIME COMPLETED 0300 AM 0 PM OX From To Ft. in. in.
4.WELL LOCATION: 10.SAND/GRAVEL PACK:
CITY: SUGAR GROVE COUNTY WATAUGA Depth Size Material
From To Ft.
OFF HICKS RD, OFF MAST GAP RD, OFF 321, OFF 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) i ,
May be in degrees, From To i Formation Description
LATITUDE _ — 36.24547N minutes,seconds or 0 30 DIRT
LONGITUDE 81.79016W in a decimal format 30 65 UNCONSOLIDATED ROCK DIRT
— — 65 120 GRANITE
Latitude/longitude source: X GPS 0 Topographic map 120 121 CREVIS
(location of well must be shown on a USGS topo map and 121 175 SHALE',GRANITE
attached to this form if not using GPS) 175 205 REDIROCK,LIMESTONE
5.WELL OWNER I i _
OWNER'S NAME DAVID HARMON I Iry I--, '1, !-- ;
STREET ADDRESS 305 HICKS RD
-.SUGAR GROVE NC 28679 __- NOV o 2023
City or Town State Zip Code
( 828 )_ 406-3804 t�' C,; ._,_�• 31j1 i
Area code- Phone number 12. REMARKS:
15 GPM 120-121
6.WELL DETAILS: 1' i
a. TOTAL DEPTH: 205
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: 30 FT. RECORD H BEEN P VI TO THE WELL I WNER.
(Use"+"if Above Top of Casing) /(
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d. TOP OF CASING IS 1 FT.Above Land Surface*
*Top of casing terminated at/or below land surface may require SIGNATURE OF CERTIFIE WELL CONTRACTOR DATE
a variance in accordance with 15A NCAC 2C.0118. RANDALL MAIN i
e. YIELD(gpm): 15 METHOD OF TEST AIR PRINTED NAME OF PERSONICONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Informaltion Mgt., Form 1617 Mail Service Center—Raleigh,NC 27699-1617 Phone No.[phone] ext 568.! I Rev.0W 1a

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