GW1--07251_Well Construction - GW1_20231108

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RESIDENTIAL WELL CONSTRUCTION RECORD
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' �p' North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 3867 230020
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 38
RANDALL MAIN g. WATER ZONES(depth):
Well Contractor(Individual)Name - From 120 To 122
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 100 Ft. 6 1/4 188' GAl 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#(if applicable) From 0 To 20 Ft. BENTONIT GRAVITY
From To IFt. 48 BAGS
WELL CONSTRUCTION PERMIT#382077 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 10/24/2023 From To Ft. in. in.
TIME COMPLETED 0300 AM 0 PM DX From To Ft. ' in.• in.
4.WELL LOCATION: 10.SAND/GRAVEL PACK:
CITY: CRESTON COUNTY ASHE Depth Size Material
From To Ft.
OFF CHERRY TREE LN OFF W. PEAK CREEK RD ( From To Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) • From - To Ft.
TOPOGRAPHIC/LAND SETTING:
o Slope u Valley 0 Flat o Ridge II Other
(check appropriate box) 11. DRILLING LOG
May be in degrees, From To Formation Description
LATITUDE •_ _ minutes,seconds or 0 95 DIRT MUD ROCK •
LONGITUDE in a decimal format 95 120 GRANITF QUARTZ
— — 120 122 VAIN
Latitude/longitude source: X GPS o Topographic map 122 160 GREY GRANITE . •
(location of well must be shown on a USGS topo map and 160 200 BLACK GRANITE
attached to this form if not using GPS)
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5.WELL OWNER I
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OWNER'S NAME THOMAS STEFFENS _ _ _
STREET ADDRESS 407 VICTOR HUGO DR '; w L.° ..`',.'• r
CARY NC 27511 City or Town State Zip Code 1!'rn1
V 0 S n)3
( 919 )_ 349-2723 :i
Area code- Phone number 12. REMARKS: ln' "'p r Y:,� t,n`D: �fi. t. ! '
24 GPM 120-122 y
6.WELL DETAILS:
a. TOTAL DEPTH: 200
b. DOES WELL REPLACE EXISTING WELL? YES il 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: 20 FT. RECOR HAS BE N P VIDED TO THE WELL OWNER.
(Use"+"if Above Top of Casing) e
d. TOP OF CASING IS 1 _ FT.Above Land Surface" ��� -��
*Top of casing terminated at/or below land surface may require SIGNA URE OF CERTI IED,W LL CONTRACTOR DATE
a variance in accordance with 15A NCAC 2C.0118. RANDALL MAIN .
e. YIELD(gpm): 24 METHOD OF TEST AIR PRINTED NAME OF PERSON CONSTRUCTING THE WELL
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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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