GW1-2021-03934_Well Construction - GW1_20210823

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RESIDENTIAL WELL CONSTRUCTION RECORD
" North Carolina Department of Environment and Natural Resources-Division of Watei Quality
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WELL CONTRACTOR CERTIFICATION# 2780 210126
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1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 34
KEITH PRESNELL
g. WATER ZONES(depth):
Well Contractor(Individual Name) From 100 To 101 From 130 To 131
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 286Q!] Depth Diameter Weight Material
From. 0 To 50 Ft 6.118- .350 PVC
City or Town State Zip Code From To Ft.
( M )-264-2651 From To Ft`.
Area code-Phone number
2.WELL INFORMATION: 7.GROUT Depth � Material Method
From 0 To 20 Ft-:BENTONIT Gravity Flow
-- -- —------ -- -- - -—-- -------- r —-- —SITE WELCID#(if appiicaliie) - From- To - Ftl` '-'
STATE WELL PERMIT#(if applicable) From To Ft.
DWQ or OTHER PERMIT#pf applicable) 162535 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply From To Ft. in. in.
DATE DRILLED 8/10/2021 From To Ft. in. in.
TIME COMPLETED 03:00 AM❑ PM K] From To Ft. in. in.
9.SAND/GRAVEL PACK:
3.WELL LOCATION:
Depth Size Material
CITY. VHAS COUNTY WS agW From To Ft.
1359BETBELRD OFF OFF HWY 321 OFF HWY 421 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 40 DIRT/GRAVEL
May be in degrees,
LATITUDE 3 _ 36`293277 minutes,seconds or 40- 100 GRANITE
LONGITUDE -81.841203 in a decimal format 100 101 CREVICE/QUARTZ .
Latitude/longitude source: Of GPS ❑Topographic map 101 110 QUARTZ
(location of well must be shown on a USGS topo map and 110 130 GRANITE
attached to this form if not using GPS) 130 131 CREVICE
4.WELL OWNER 131 180 IUARTZ MD
OWNER'S NAME PAULDIBELLALIVINGTRUST,
STREET ADDREssl359 BETHEL RD.
VILP,S NC 28M
City or Town State Zip Code
(( 678) )_523-6439
Area code-Phone number
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 180 7 GPM 100- 101 13 GPM 130- 131
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOXI
c. WATER LEVEL Below Top of Casing: 20 FT. I DO HEREBY CERTIFY THAT THIS WELLwAS CONSTRUCTED IN ACCORDANCE WITH
(Use"+"if Above Top of Casing) 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
RE RD HAS BEEN PROVIDEF
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 SIGNATURE OF CERTIF ED WELL CONTR611713 DATE
e. YIELD(gpm): 20 METHOD OF TEST Air KITH PRI=gAIGI I I 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 568.1 Rev.7/05

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