GW1-2021-01976_Well Construction - GW1_20210527

RESIDENTIAL WELL CONSTRUCTION RECORD
- C North Carolina Department of Environment and Natural Resources-Division of Water Quality
2?80 1 2100137
WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR:KEITH PRESNELL- HTH
f. DISINFECTION:Type I Amount 45
- i
g. WATER ZONES(depth):
Well Contractor(Individual Name) From 0 To 800 From 960To
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:
City or Town State Zip Code From To Ft.
( = )--264-2651 From To Ft.
Area code-Phone number 7.GROUT: Depth Material Method
2.WELL INFORMATION: From To Ft. GravityFlow
SITE WELL ID#Qf applicable) From To Ft. -
STATE WELL PERMIT#(if applicable) From To Ft.
DWO or OTHER PERMIT#(if applicable) 56996 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply❑ From To Ft. in. in.
DATE DRILLED 412112021 X From To Ft. in. in.
TIME COMPLETED ()-A•M AM❑ PM W From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
Depth Size Material
CITY: DRTLS,DEEPEtz COUNTY BTTRKE From To Ft.
From To Ft.
OFF WRE EMONT RD OFF SALEM RD OFF HWY 64 From To Ft.
(Street Name,Numbers,Communit)A 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, 9 am $I.:vt11.1 --VML
LATITUDE 3 _ minutes,seconds or w960 (ZRANITE1011ART7
LONGITUDE in a decimal format
gnf±F
Latitude/longitude source: WPS ❑Topographic map 960 1120 GRANITE
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4.WELL OWNER
OWNER'S NAME BW IMIMARDT
@�
STREET,ADDRESS IAR MONTRR AV OAKS rr rT
/ 2021
Iwo own State Zip
(=3).)- 41� .__ tg�processing
Area code-Phone number 1 D 3 n1.ru R section
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 1-120 0.125GM01 n_onn n 12sue
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO k,
c. WATER LEVEL Below Top of Casing: OM FT. I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
(Use"+"if Above Top of Casing) 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED T E WELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land Surface' L , ,
Top of casing terminated at/or below land surface may require `� 44,5 a variance in accordance with 15A NCAC 2C.0118 SIGNAT CERTIFIED CO R DA E
e. YIELD(gpm): 0�,5 METHOD OF TEST I 1
PRINT 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 568.i Rev.7/05

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