GW1-2021-00357_Well Construction - GW1_20210127

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RESIDENTIAL WELL CONSTRUCTION REC OR`D
- C North Carolina Department of Environment and Natural Resources-Division of Water Quality 4 y`
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WELL CONTRACTOR CERTIFICATION# 2780 200214E
1.WELL CONTRACTOR: CHTH
KEITH PRESNELL If. DISINFECTION:Type Amount 30
g. WATER ZONES(depth):
Well Contractor(Individual Name) From 50 To 51 From 177TO 179
DEWEY WRIGHT WELL&PUMP CO., INC.
From To From To
Well Contractor Company Name From To From To
STREET ADDRESS p O.BOX 30$ 6.CASING: Thickness/
BOONE NC 22607 Depth Diameter Weight Material
From 0 To 42 F{ 6118 .350 PVC
City or Town State Zip Code From To Ft.
( = )-264-2651 - From To Ft.
Area code-Phone number
2.WELL INFORMATION: 7.GROUT: Depth ` Material Method
From 0 To 20 Ft. Cement Pubam
SITE WELL ID#(ifapplicable)_ _ _ - — _ _- - From --_. To_-- Ft._-_ _
STATE WELL PERMIT#(if applicable) From To Ft.
DWO or OTHER PERMIT#(if applicable) 332953 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply LY From To Ft. in. in.
DATE DRILLED 1/12/2021 From To Ft. in. in.
TIME COMPLETED 03:00 AM❑ PM INFrom To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
Depth Size Material
CITY: V.AS COUNTY Wama From To Ft.
1779 MO=AW DALE RD OFF BETHM RD OFF H From _To Ft.
From To Ft.'
(Street Name,Numbers,Communit)4 Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
❑Slope ❑Valley ❑Flat ❑Ridge ❑Other From To Formation Description
(check appropriate box) 0 30 MUDA30ULOERS
May be in degrees,
LATITUDE 3 _ N36*12.522 minutes,seconds or 30 50 BLUE GRANITE
LONGITUDE W081*42.388 in a decimal format 50 51 CREVICE
Latitude/longitude source: OIGPS ❑Topographic map 51 162 LIMESTONE
(location of well must be shown on a USGS topo map and 162 177 BLUE GRANITE
attached to this form if not using GPS) 177 178 QUARTZICREVICE
4.WELL OWNER 178 185 BLUE GRANITE
OWNER'S NAME laCHEUX HSMSON _
STREET ADDRESS 1779 MOUNTAIN DALE RD,
VIL.AS NC 2M
City or Town State Zip Code,
((8= _ 20-2709
Area code-Phone number
5.WELL DETAILS: -11.,REMARKS:
a. TOTAL DEPTH: 185 0.5 GPM 50-51 14.5 GPM 177-I78
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOW
c. WATER LEVEL Below Top of Casing: 40 FT. I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
(Use"+"if Above Top of Casing) 5A NCAc zc,WELL CONST ION STANDARDS,AND THAT A COPY OF THIS
ORD HAS BEEN PROVID D O THE WELL OWNER.
d. TOP OF CASING IS I FT.Above Land Surface*
*Top of Casing terminated at/or below land surface may require yu
a variance in accordance with 15A NCAC 2C.0118 SIGNATURE OF CERTIF TOR DATE
e. YIELD(gpm): 15 METHOD OF TEST Air KEITH PRESNELL
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
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 566. Rev.7/05
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