GW1-2021-03543_Well Construction - GW1_20210607

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RESIDENTIAL WELL CONSTRUCTION RECORD i
0 North Carolina Department of Environment and Natural Resources-Division of Water Quality
210040
WELL CONTRACTOR CERTIFICATION# 2780 ?
1.WELL CONTRACTOR: HTH
KEITH PRESNELL f. DISINFECTION:Type Amount 91
g. WATER ZONES(depth):
Well Contractor(Individual Name) From-489 To 499 From To
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 M&P Depth Diameter Weight Material
From 0 To 28 Ft. 6118 .350 PVC
City or Town State Zip Code
2C�4-2651 From To Ft.
( )- From To Ft.
Area code-Phone number
2.WELL INFORMATION: 7.GROUT Depth Material Method
From 0 To 20 Ft•BE1TTOMTT Gravity Flow
i SITE WELL ID#if applicable) _ - - -From .__ To- --Ft.- _
STATE WELL PERMIT#(if applicable) From To Ft.
DWQ or OTHER PERMIT#(if applicable) 3295" &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply IN From To Ft. in. in.
DATE DRILLED 5/2&2021 From To Ft. in. in.
TIME COMPLETED 03:00 AM❑ PM From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
Depth Size Material
CITY: VELAS COUNTY Wat = From To Ft.
OFF BETHE L RD OFF HWY 321 OFF HWY 421 OFF 10 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) May be in degrees, n 1R nIRTIROCK
LATITUDE 3 _ minutes,seconds or 18 28 GRAY GRANITE
LONGITUDE in a decimal format 28 . 488 BLUE&GRAY GRAND
Latitude/longitude source: L@GPS ❑Topographic map 448 489 BIG CREVICE
(location of well must be shown on a USGS topo map and 489 SW - DARK GRAY GRANITE
attached to this form if not using GPS)
4.WELL OWNER
OWNER'S NAME DARP"&WJNICE RUDBR. 'Q
STREET ADDRESS9%PHIL BRYAN, 832 PIEDMONT SCHOOL RD
DENTON NC 27239
City or Town State Zip Code
(( 336) )_ 302-5486 Processing
Area code-Phone number tr�Tr �DWR SeCC!Dn
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 505 30 GPM 488-489
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOKI
c. WATER LEVEL Below Top of Casing: b0 FT. I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
(Use"+"if Above Top of Casing) 15A NCAC 2C,WELL CONS
TR TION,STANDARDS,AND THAT A COPY OF THIS
RE ORD HAS BEEN PROW D O THE 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 C011TPACtOR DATE
30 Air KEITH PRESNELL�
e. YIELD(gpm): METHOD OF TEST
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. 1 Rev.7/05
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