GW1-2021-00540_Well Construction - GW1_20210219

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RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department.of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 7780 200M
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 67
KEITH PRESNELL
g. WATER ZONES(depth):
Well Contractor(Individual Name) From 350 To 351 From 419TO 420
DEWEY WRIGHT WELL&PUMP CO., INC.
From To From To
Well Contractor Company Name From To From To
STREET ADDRESS P.O.BOX 308 6.CASING: Thickness/
BOONS NC 28607 Depth Diameter Weight Material
From 0 To 92 Ft. 61/8 .350 PVC
City or Town State Zip Code From To Ft.
( = )-264-2651 From To Ft.
Area code-Phone number 7.GROUT: Depth Material Method
2.WELL INFORMATION: From-0 To 20 Ft. BEh1T01M GravitgFlow
SITE WELL ID#(if applicable) `From To Ft. 25 RAGSRAGSSTATE WELL PERMIT#(if applicable) From To Ft.
DWO or OTHER PERMIT#(if applicable) 262173 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply From To Ft. in. in.
DATE DRILLED 2J5/2021 From To Ft. in. in.
TIME COMPLETED AM❑ PM From To Ft. in. in.
3.WELL LOCATION:
9.SAND/GRAVEL PACK:
”
Depth Size Material
CITY: TODD COUNTY A—%M From To Ft.
OFF MILT HOUCK OFF LAUREL KNOB RD OFF HW From TO Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) From _To Ft..
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
❑Slope ❑Valley ❑Flat ❑Ridge ❑Other From To Formation Description
(check appropriate box) 0 82 DIRT
N36+05.026 May be in degrees,
LATITUDE 3 minutes,seconds or 82 3W GRAY GRANITE
LONGITUDE W081*51.613 in a decimal format 350 351 CREVICE
Latitude/longitude source: JI(GPS ❑Topographic map 351 419 BLUE GRANITE
(location of well must be shown on a USGS topo map and 419 420 CREVICE
attached to this form if not using GPS) 420 425 BLUE GRANITE
4.WELL OWNER
OWNER'S NAMEDAVM&KATHRYN LADD
STREET ADDRESS%WALL TO WALL CONSTRUCTION, 366VFI
RZET'WOOD - NC 28626._
City or Town State RE i r"
( (SM )_ 964-1289 EN Mu
Area code-Phone number Q 2021
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 425 Information Processing Unit 0.5 GPM 350-351 49.5 GPM 419-420
b. DOES WELL REPLACE EXISTING W yR)qpS&n NOV
C. WATER LEVEL Below Top of Casing: 100 FT. I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
(Use"+"if Above Top of Casing) 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT COPY OF THIS
RECORD HAS BEE PROVIDE E WELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land Surface' t
*Top of casing terminated at/or below land surface may require 1
a variance in accordance with 15A NCAC 2C.0118 SIGNATURE OF CERTIFIEDWELL CONTR T
R DATE
e. YIELD(gpm): 50 METHOD OF TEST Air KEITH PRESNELL
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days.Attn:Information Mgt., Form GW-1 a
1617 Mail Service Center-Raleigh,NC 27699-1617 Phone No.[phone] ext 568. Rev.7/