GW1-2021-07101_Well Construction - GW1_20210915

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RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 2780 I 21WFi-2
1.WELL CONTRACTOR: f. DISINFECTION:Type k TN Amount
72
KEITH PRESNELL
g. WATER ZONES(depth):
Well Contractor(Individual Name) From 3n5 To 306 From 1Stn TO Is')
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/
Depth Diameter Weight Material
$GONE NC B From 0 Tom Ft. A 1/R 150 gVC
City or Town State Zip Code From To Ft:
( 828 )-264-2651 From To Ft.
Area code-Phone number
2.WELL INFORMATION: 7.GROUT: Depth Material Method
From 0 To 20 Ff.$M= l3twitmEau
—SITE-WELLID#(fapplicable) -----—From- -` To Ftc ¢RAC-A
STATE WELL PERMIT#(if applicable) From To Ft.
DWO or OTHER PERMIT#(if applicable) 354525 B.SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply From To Ft. in. in.
DATE DRILLED 9/2S/2021 From To Ft. in. in.
TIME COMPLETED 03:00 AM❑ PM 10 From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
Depth Size Material
CITY; SUGAR GROVE COUNTY W92= From To Ft.
OFF ANDY HICKS RD-OFF SPICE CRE>3K.RD OFF RO 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) 0 15 DIRT
May be in degrees,
LATITUDE 3 36.21344$ minutes,seconds or 15 305 GRANITE
LONGITUDE -81.854588 in a decimal format 305 306 _ CREVICE-
Latitude/longitude source: ®GPS ❑Topographic map 306 - 380 GRANITE
(location of well must be shown on a USGS topo map and 380 . 3132. CREVICE
attached to this form if not using GPS) 382 42D GREEN GRANITE
4.WELL OWNER
OWNER'S NAMEF=&LAURA TANNER
STREET ADDRESS134 WINTERGREEN-RD
V MbUNGTON NC 2" e fAffi
City or Town State Zip Code
( 10) )_612-8148 3�- ) 1(9
Area code-Phone number4QCY;00
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 420 5 GPM 305-" 15 GPM 380-392
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO)0
c. WATER LEVEL Below Top of Casing: 60 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 AS BEEN PROVIDED T E 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 StNAT_DAt'0_F CERTIVIED WELL CONTRA5T4rA DATE
e. YIELD(gpm): 20 METHOD OF TEST Air KEITH PRESNEL I
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
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