GW1--00082_Well Construction - GW1_20231228

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5.:7; RESIDENTIAL WELL CONSTRUCTION RECORD
"l`if s North Carolina Department of Environment and Natural Resources-Division ofj Water Quality
'`.4,, `.,„ . WELL CONTRACTOR CERTIFICATION# 3867 220206
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1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 40
RANDALL MAIN g. WATER ZONES(depth):
Well Contractor(Individual)Name From 90 To 92 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 37 Ft. 6 1/4 188 GAI \/
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 37 Ft. CEMENT PUMPED
BSI?E_WELLAD_#(if_applicable)-_...,. _ - -,---_--_-- - - —- -.--- - -
mom To ht
WELL CONSTRUCTION PERMIT#373217 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 11/20/2023 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: TODD COUNTY ASHE Depth Size Material
From To Ft.
OFF SUTHERLAND RD OFF 67/88 OFF 421N - 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) -
May be in degrees, From To Formation Description
LATITUDE _ 36.37153N minutes,seconds or 0 30 DIRT,ROCK
LONGITUDE_ 81.57559w in a decimal format 30
80
90 GRANITE
Latitude/longitude source: X GPS 0 Topographic map 90 92 VAIN
(location of well must be shown on a USGS topo map and 92 160 GRANITE QUARTZ
I attached to this form if not using GPS) 160 200 GREY GRANITE
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5.WELL OWNER
OWNER'S NAME LARRY MONROE
STREET ADDRESS PO BOX 1356 `,. • ' ' 'Le '' ,o.""``,,
WEST JEFFERSC NC 28694 .
City or Town State Zip Code 1)` (, 7. 8 2023
( 828 )- 964-3776 Iaicm-r.-:.•`.i f n f14^l,]
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Area code- Phone number 12. REMARKS: `""- (y
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10 GPM 90-92 '
6.WELL DETAILS: LINER PIPE-37' '
a. TOTAL DEPTH: 200
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: 10 FT. RECORD AS BEEN PR' IDED TO THE WELL OWNER.
(Use"+"if Above Top of Casing) / // A
/2-/-)-3
d. TOP OF CASING IS 1 FT.Above Land Surface*
*Top of casing terminated at/or below land surface may require SI NATURE OF CERTIFIED WELL CONTRACTOR DATE
a variance in accordance with 15A NCAC 2C.0118: RANDALL MAIN ' I
e. YIELD(gpm): 10 METHOD OF TEST AIR PRINTED NAME OF PERSON1CONSTRUCTING THE WELL
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Submit the original to the Division of Water Quality within 30 days. Attn: Informati In Mgt., Form GW-la
1617 Mail Service Center-Raleigh, NC 27699-1617 Phone No.[phone] ext 568. Rev.3/07
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