GW1-2021-00358_Well Construction - GW1_20210127

a Kc SfATt v
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
ww�°
WELL CONTRACTOR CERTIFICATION# 2780 200M
1.WELL CONTRACTOR:
f. DISINFECTION:Type_ uTu Amount 96
KEITH PRESNELL g. WATER ZONES(depth):
Well Contractor(Individual Name) From 161 To From jn—cTo
DEVVEY WRIGHT WELL &PUMP CO., INC. From To FromTo
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 Tom_ Ft._ 61IR 350 PVC
City or Town State Zip Code From To Ft.
(AM )-264-2651 From To Ft.
Area code-Phone number 7.GROUT: Depth Material Method
2.WELL INFORMATION: From 0 To20 Ft._RMTT= C8gjtyFICW
SITE WELL ID#(if applicable) From To Ft._
STATE WELL PERMIT#(if applicable) From To Ft._
DWQ or OTHER PERMIT#(if applicable) 0331W &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply LX From To Ft._ in. in.
DATEDRILLED 11512021 From To Ft._ in. in.
TIME COMPLETED 03:00 AM❑ PM A From To Ft._ in. in.
9.SAND/GRAVEL PACK:
3.WELL LOCATION:
Depth Size Material
CITY: rR IZU CREEK COUNTY Wi= From To Ft.
LOT 19 OFF GRINDSTONE LN OFF HWY 16 OFF HW From _To Ft. _
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) n 57 SANDIGRAVPI
May be in degrees, --
LATITUDE 3 N35* A6K minutes,seconds or 57 84 _— RFD CHEI F ROCK
LONGITUDE W081 wr.397 in a decimal format 84 365 _— GRANITE
Latitude/longitude source: AGPS ❑Topographic map W5 365 _ CREVICE
(location of well must be shown on a USGS topo map and 355 SIM GRANITE/QIIARTTZ
attached to this form if not using GPS) 5b5 SIM VdIC
4.WELL OWNER SIDS 600 _ GRANITE
OWNER'S NAME CAFE BNB CH M
STREET ADDRESS3516 LEGENDS DR
SOUTHEIM PINES NC 28387
City or Town State Zip Code
(3( 52) )- 422-Ml Area code-Phone number
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 6W 0 5 GPM 365- 0 i('PM S05-
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOW —
c. WATER LEVEL Below Top of Casing: 120 FT, I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
(Use"+ if Above Top of Casing) 15A NCAC 2C,WELL CONSTRUCTIO STANDARDS,AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO T WELL OWNER.
d. TOP OF CASING IS 1 FT Above Land Surface' L' / ,1
Top of casing terminated at/or below land surface may require 6�v') I
a variance in accordance with 15A NCAC 2C.0118 SIGN RTIFI OF CEED ELL CONTRA OR DATE
e. YIELD(gpm): 1 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.7/05
1

- - - - rn
to k
Y
IOrn;leS 1
r:.. :_7'
�r