GW1-2021-03691_Well Construction - GW1_20210823

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RESIDENTIAL WELL CONSTRUCTION RECORD ;
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North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# rrgn I 210021
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1.WELL CONTRACTOR: "
f. DISINFECTION:Type HTH Amount 31
KEITH PRESNELL g. WATER ZONES(depth)
Well Contractor(Individual Name) From 137 To 138 From To
DEVVEY VVRIGHT 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/
BOONS- NC 2$607 Depth Diameter Weight Material
From 0 Tom Ft. 61/4 .188 GAT V
City or Town State Zip Code From To Ft.
( = )-2,64-2651 From To Ft.
Area code-Phone number 7.GROUT: Depth Material Method
2.WELL INFORMATION: From 0 To 20 Ft.BENTONTT GravityFlova
SITE WELL ID#(if applicable) From To Ft.
STATE WELL PERMIT#(if applicable) From To Ft.
DWO or OTHER PERMIT#(If applicable) 763588 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply From To Ft. in. in.
DATE DRILLED 8/1&2021 From To Ft. in. in.
TIME COMPLETED 03:()0 AM❑ PM I[I From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
BANNERTLK AVERY Depth Size Material
CITY: COUNTY From To Ft.
2019 CURnS CRffis RD/125 DREAM CATERS WAY From _To Ft.
From To Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
❑Slope ❑Valley ❑Flat ❑Ridge ❑Other From To Formation Description
(check appropriate box) 0 32 DIRT
May be in degrees,
LATITUDE 3 _ N36*19.604 minutes,seconds or 32 137 BLUE GRANITE
LONGITUDE _ W081*50.765 in a decimal format 137 138 CREVICEIGUARTZ
Latitude/longitude source: IN GPS ❑Topographic map 13B 165 BLUE GRANITE
(location of well must be shown on a USGS topo map and"
attached to this form if not using GPS)
4.WELL OWNER
OWNER'S NAMEI= FRY @'
STREET ADDRES43505 HIDDflNBROOK DR,
TAWA FL 33624
City or Town State Zip Code A1`C, 1
($( 13) ) 380-8631 re StC�9
Area code-Phone number 11i1Cf �^,9 caect on
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 165 20 GPM 137-138
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO%]
c. WATER LEVEL Below Top of Casing: 15 FT. I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
} (Use"+"if Above Top of Casing) 15A NCAC 2C,WELL CONSTRUCT ON STANDARDS,AND THAT A COPY OF THIS
R ORD HAS BEEN P OVIDED 0 HE WELL OWNER.
d. TOP OF CASING IS 1' FT.Above Land Surface* I* '�C '�
"Top of casing terminated at/or below land surface may require W'J /
a variance in accordance with 15A NCAC 2C.0118 IGN OF CERTrFIE E LL MRTRAMOR DATE
e. YIELD(gpm): 20 METHOD OF TEST Au KEITH PRESIVELL
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., 1 Form GW-1a
1617 Mail Service Center-Raleigh, NC 27699-1617 Phone No.[phone] ext 568. 1 Rev.7/05
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