GW1-2021-03286_Well Construction - GW1_20210603

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.: RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
2780 210013
WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 94
KEITH PRESNELL
g. WATER ZONES(depth)'.
Well Contractor(Individual Name) From 140 To From 325TO
DEWEY WRIGHT WELL&PUMP CO., INC.
From 440 To From 485To
Well Contractor Company Name From To From To
STREET ADDRESS P.O.SOX 308 6.CASING: Thickness/
SOONE• NC 28M Depth Diameter Weight Material
From 0 To 46. Ft. 61I8 .350 PVC
City or Town State Zip Code From To Ft.
( M8 )-264-2651 From TO Ft.
Area code-Phone number
2.WELL INFORMATION: 7.GROUT: Depth Material Method
-From 0 To ' 20 Ft.$ENTONIT Gravity Flow
SITE WELL ID#(if applicable) From To Ft.'21 SAGS
STATE WELL PERMIT#(if applicable) From To Ft. SEIFCERERT
DWQ or OTHER PERMIT#(if applicable) &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply C From To Ft. in. in.
DATE DRILLED 5/2112021 �t From To Ft. in. in.
TIME COMPLETED AM❑ PM Ll From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
Depth Size Material
CITY: LENOIR COUNTY CAIDVvW.L From To Ft.
LOT 7 OFF ROSY MARTIN RD OFF At75'TIN VALLE 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 24 SAND/GRAVEL
_ N35�59.8r May in degrees, 24 140 GRANITE
LATITUDE 3 minutes,seconds of
LONGITUDE Udllft1 9450 in a decimal format 140 140 CRSACE
Latitude/longitude source: LYGPS ❑Topographic map 140 325 GRANITE
(location of well must be shown on a USGS topo map and 325 325 CREVICE
attached to this form if not using GPS) 325 440 GRANITE
4.WELL OWNER 440 440,7 CREVICE
OWNER'S NAME ARAM VENGUM 440 485 GRANITE
STREET ADDRESSPO BOX 485 485 CRE\4CE-
GP—k= NC 28630 485 525 GRANITE
City or Town State Zip Code
( = 1 234-6871
Area code-Phone number
5. DETAILS: 11 P�S
0.5 GPM 140- 0.5 GPM 325-
a. TOTAL DEPTH: 525 Qct'°r
a. TO
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO 0.5 GPM 440- 0.5 GPM 485V
c. WATER LEVEL Below Top of Casing: 55 FT 1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
(Use"+"if Above Top of Casing) t 5A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED THE WELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land Surface*
*Top of casing terminated at/or below land surface may require OROl
a variance in accordance with 15A NCAC 2C.0118 SIGNATOFTE OF CERTIFIED WELL COtTTRACMR DATE
e. YIELD(gpm): 2 METHOD OF TEST Air KEITH PRESNELL
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
r �
t :
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 2769971617 Phone No.[phone] ext 568.1 Rev.7/05
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