GW1-2021-05883_Well Construction - GW1_20211025

ii
I
STAIF
..m,�
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
2780 f 210185
WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 26
KEITH PRESNELL
g. WATER ZONES(depth):
Well Contractor(Individual Name) From 80 To 82 From 122 To 123
DEWEY WRiGH T WtLL &PUMP CO.. iNC. From To From To
Well Contractor Company Name From TO From To
STREET ADDRESS P.O.BOAC 308 6.CASING: Thickness/
BOONE NC 28607 Depth Diameter Weight Material
From O To 42 Ft. 6114 .188 QOALV
City or Town State Zip Code From To Ft.
( US )264-2651 From To Ft.
Area code-Phone number
2.WELL INFORMATION: 7.GROUT: Depth Material Method
From O To 20 Ft.BENTONTT &avityFlow
-- - - - — —-— 5
SITE WELL ID#pf applicable) From To Ft. 2MAGS
STATE WELL PERMIT#(if applicable) From To Ft.
DWQ or OTHER PERMIT#(if applicable) 363589 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check AD licable Box): Residential Water Supply From To Ft. in. in.
DATE DRILLED G14/2021 From To Ft. in. in.
TIME COMPLETED AM❑ PM From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
WEST IF31F'ERSON p4�gr ' Depth Size Material
CITY: COUNTY From To Ft.
777 BUCK MTN RD OFF BUCK L1TN CIR OFF BALD From _TO Ft.
From TO Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
❑Slope ❑Valley Ll Flat ❑Ridge ❑Other From To Formation Description
(check appropriate box) 0 35 DIRT/MUDIROCKS
LATITUDE 3 minutteos,seconds or
36.392111 May in degrees, 35 so GRANITE
LONGITUDE -81.511013 in a decimal format 80 82 QUARTZ
Latitude/longitude source: 21 GPS ❑Topographic map 82 122 GRANITE
(location of well must be shown on a USGS topo map and 122 123 VOID
attached to this form if not using GPS) 123 124 QUARTZ
4.WELL OWNER 124 145 i GRANITE
,onraNIERD
OWNER'S NAMEGARY S=ART
STREET ADDRESSI 51 LINDEN LOOP,
STONY POINT NC
City or Town State Zip Code pT0reS8109 `
( (704) ) 903-8212 1001M3.�la Se
dOO
Area code-Phone number
5. DETAILS: 145 11.REMARKS:
a. TOTAL DEPTH: GPM 80-82 16 GPM 122- 123
a. TO
b. DOES WELL REPLACE EXISTING WELL? YES❑ NA
c. WATER LEVEL Below Top of Casing: 20 FT. I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
(Use"+"if Above Top of Casing) 15A NCAC 2C,WELL CONSTRUgTION STANDARDS,AND THAT A COPY OF THIS
RECORD HAS BEEN PRpVIDEWTP THE WELL OWNER.
d. TOP OF CASING IS 1 FT Above Land Surface* 1 �M1%,,
*Top of casing terminated at/or below land surface may require 40
a variance in accordance with 15A NCAC 2C.0118 IGNATURE OF CER FIED;WELL CONTRAC OR DATE
e. YIELD(gpm): 20 METHOD OF TEST Air KEITH PRESNELL
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
I

k - _
r ,
sa`
rya .Ti...
r P y
1 t�
t