GW1-2021-06599_Well Construction - GW1_20211007

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RESIDENTIAL WELL CONSTRUCTION RECORD
- C North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 2780 210154
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1.WELL CONTRACTOR: HTH Amount 120
KEITH PRESNELL f. DISINFECTION:Type
g. WATER ZONES(depth):;
Well Contractor(Individual Name) From 300 To 301 From 515 T0516
DEWEir WiRiGHT WELL &PUMP CO., INC. From To i 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 0 To 100 Ft. 61/8 .350 FVC
City or Town State Zip Code From To Ft.
( 828 )-264-2651 From To Ft.
Area code-Phone number 7.GROUT: Depth Material Method
2.WELL INFORMATION: From 0 To 20 Ft.BENTONIT GtavityFlow
SITE WELL ID#(if applicable) From To Ft:25-BAGS—
STATE WELL PERMIT Of applicable) From To Ft.
DWQ or OTHER PERMIT#(if applicable) 357701 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply From To Ft. in. in.
DATE DRILLED 9/2 N2MI 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: FLEEMOOD COUNTY ASHE From To Ft.
OFF OUR=Y.CIRCLE OFF TROJAN HORSE OR 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 70 CLAY
_ _ 36.2?4452 May be in degrees,
LATITUDE 3 minutes,seconds or 70 90 SANDSTONE
LONGITUDE -81.476904 in a decimal format 90 s GRANITE
Latitude/longitude source: IN GPS ❑Topographic map 3W 301 CREVICE
(location of well must be shown on a USGS topo map and 301 500 GRANITE _
attached to this form if not using GPS) 500 515 QU
4.WELL OWNER 515 516 CR
OWNER'S NAME' IN ROMINGER 516 600 UMESTQNET A Z
STREET_ADDRESS�LS COWBOY TRAIL, 600 700 GRANIT n lint
DEEP GAP NC 28618 QteceSst��—
City or Town State Zip Code 1(10 " D\rrgp 8v
964•-3486
Area code-Phone number
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 700 0.5 GPM 300-301 1 GPM 515-516
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOX3
c. WATER LEVEL Below Top of Casing: 100 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
REP
QRD HAS BEE P OVID THE WELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land Surface* U��(J P
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C.0118 SIGNATURE OF RTIFI D LL CON AC OR DATE
e. YIELD(gpm): 1.5 METHOD OF TEST Air KEITH PRESNEL C
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
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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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