GW1-2021-01241_Well Construction - GW1_20210209

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RESIDENTIAL WELL CONSTRUCTION RECO+{RD
- L North Carolina Department of Environment and Natural Resources-Division of Water Quality
' WELL CONTRACTOR CERTIFICATION# 1
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1.WELL CONTRACTOR: f. DISINFECTION:Type Amount
KEITH PRESNELL
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g. WATER ZONES(depth):
Well Contractor(Individual Name) From 291 TO 294 From 62gTo 629
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/
BOONE NC 28607 Depth Diameter Weight Material
From To Ft. 6148 ,35n � IC
City or Town State Zip Code From To Ft.
O-264-2651 From To Ft.
Area code-Phone number
2.WELL INFORMATION: 7.GROUT: Depth Material Method
From 0-To _20 Ft. BMUO= Girgpim Fipap
SITE WELL ID#(if applicable) From--To— Ft.-38'RAGS
STATE WELL PERMIT Of applicable) From To Ft.
DWO Or OTHER PERMIT#(if applicable) 320213 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply From To Ft. in. in.
DATE DRILLED . 101/2021 - From To Ft. in. in.
TIME COMPLETED 03:00 AM❑ PM 04 From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
Depth Size Material
CITY: BOONE COUNTY wdsl l From To Ft.
LOT 22 OFF CEZANNE From To Ft.DR OFF SORRENTO DROFF From To Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
❑Slope ❑Valley ❑Flat ❑Ridge ❑Other From TO Formation Description
(check appropriate box)
May be in degrees, 0 30 DIRT
LATITUDE 3 minutes,seconds or 30 293 GRAY GRANITE
LONGITUDE in a decimal format 293 294 CREMCF
Latitude/longitude source: CJ(GPS ❑Topographic map 294—686 GRAY GRANITE
(location of well must be shown on a USGS topo map and sm 6N QI,IARTZm_REiaCE
attached to this form if not using GPS) 6M 705 GRAY GRANITE
4.WELL OWNER
OWNER'S NAME STEXgMT SVBTIK
STREET ADDRESS%4 FORT_Y FOUR; PO BOX 1967
BLOWIlMTG ROCK NC 2$605-
City or Town State Zip Code
r (8=)- 773-7582
Area code-Phone number
SWELL DETAILS: KTS:
a. TOTAL DEPTH: 705 993-294 4 5 CrPtlti f$$-689
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOW qq
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''. I DO HEREBY CERTIFY THAT THIS WELL'WAS CONSTRUCTED IN ACCORDANCE WITH
c. WATER LEVEL Below Top of Casing: 100 FT �?fl ,^
(USA"+"if Above Top of Casing) ell 15�1`NFAC• G,,W�LL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
?R R `H�At BAN PR VIDED TO T414A WELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land Surface*
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C.0118 SIGNATURE OF CERTIFIED WELL CONTRA R DATE
e. YIELD(gpm): 5 METHOD OF TEST ;Air K1=11H PRlzgNPI I -
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
I. i
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 568.1 Rev.7/05

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