GW1-2021-03690_Well Construction - GW1_20210823

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RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
2780 f 200083
WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 113
KEITH PRESNELL
g. WATER ZONES(depth):
Well Contractor(Ind_ividual Name 411 442
DEVUEY MIGHT WELL &PUMP CO., INC. From To From To
From To i From To
Well Contractor Company Name From To From To
STREET ADDRESS P O.BOX 30$ 6.CASING: Thickness/
BOONS NC 28W7 Depth Diameter. Weight Material
From 0 To 60 Ft'._ 61/8 .350 PVC
City or Town State Zip Code From To Ft.
( = )�2651 From To Ft'.
Area code-Phone number
2.WELL INFORMATION: 7.GROUT: Depth Material Method
From To Ft.BENTONIT GravitYFlow
- -- -- -
SITE WELL ID#(if applicable) From To Ft.---
STATE WELL PERMIT#(if applicable) From To Ft.
10536
DWQ or OTHER PERMIT#(if applicable) &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply From To Ft. - in. in.
DATE DRILLED From To Ft. in. in.
TIME COMPLETED AM❑ PA From To Ff. in. in.
9.SAND/GRAVEL PACK:
3.WELL LOCATION:
Depth Size Material
CITY: NE .i4ND COUNTY AVEIZY From To Ft.
9&LITTLE BUCK HILL RD OFF OFF 3 L=OFF H 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 50 DIRT
N36''nM6 May to in degrees, 60 GREY GRANITE
LATITUDE 3 minutes,seconds or
LONGITUDE , in a decimal format 60 441 GREY&BLUE GRANIT
Latitude/longitude source: 25 GPS ❑Topographic map 441 442 CREVICE/QUARTZ
(location of well must be shown on a USGS topo map and 442 605 BLUE GRANITE ,.
attached to this form if not using GPS)
4.WELL OWNER
OWNER'S NAMEE_pD= WISE
STREET ADDRESS964 LITTLE BUCK HILL RD,
NEWLAND NC 286577 Zp21
City or Town State Zip Code
765-9910 ion prooeA_sm
Area code-Phone number DWI eC'110
5.WELL DETAILS: 605 111 GPM 44: -442
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO47
C. WATER LEVEL Below Top of Casing: 50 FT. I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
(Use"+"if Above Top of Casing) 15A NCAC 2C,WELL CONSTRUC ;STANDARDS,AND THAT A OPY OF THIS
ORD HAS111EE ') VIDED T E WELL OWNER.
4
d. TOP OF CASING IS 1 FT.Above Land Surface`
Top of casing terminated at/or below land surface may require v r'
a variance in accordance with 15A NCAC 2C.0118 IGNNMM OF C TI I D ELL CONT DATE
e. YIELD(gpm): 1 METHOD OF TEST Ai KEITH PRESNEL(
PRINTED NAME OF PERSON JCONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days.Attn: Information Mgt.,
G Form GW-1a
1617 Mail Service Center-Raleigh,NC 27699-1617 Phone No.[phone] ext 568. Rev.7/05
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