GW1-2021-05885_Well Construction - GW1_20211025

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RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 2784 210138
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1.WELL CONTRACTOR:
KEITH PRESNELL f. DISINFECTION:Type HTH Amount 39
g. WATER ZONES(depth):
Well Contractor(Individual Name) From 120 To 124 From 166 To 187
DEWEY WRIGHT WELL&PUMP CO., INC. From To From To
Well Contractor Company Name From To From To
STREET ADDRESS P.0.BOX 308 6.CASING: Thickness/
BOONE NC 28607 Depth Diameter Weight Material
From 0 To 38 Ft. 61/8 .350 PVC
City or Town State Zip Code From To Ft.
( 82$ )-264-2651 From To Ft.
Area code-Phone number 7.GROUT: Depth Material Method
2.WELL INFORMATION: 0 20 $Fiji]ZONIT Gra¢itY_Flaaa— ——
— -- From- —To -- Ft.
SITE WELL ID#(if applicable) From To Ft.24BAGS
STATE WELL PERMIT#(if applicable) 291253 From To Ft.
DWQ or OTHER PERMIT#(if applicable) 8.SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply From To Ft. in. in.
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DATE DRILLED 0/8/2021 . From To Ft. in. in.
TIME COMPLETED AM❑ PM 6 From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
Depth Size Material
CITY: LANSING. COUNTY ` .SHE From To Ft.
476 COY HAM RD OFF E BIG SPRINGS RD OFF ROA 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 30 DIRT
36.530260 . May be in degrees, 30 120 GRANITE
LATITUDE 3 minutes,seconds or
LONGITUDE - in a decimal format 120 124 QUARTZ/UMESTONE
Latitude/longitude source: IN GPS ❑Topographic map 124 186 GRANITE
(location of well must be shown on a USGS topo map and 186 187 VOID
attached to this form if not using GPS) 187 205 GRANITE
4.WELL OWNER
OWNER'S NAMEODIE&ROXANE GMEERT
STREET ADDRESSa769 WATER TANK RD,
ATM JEFFERSON NC 28694
City or Town State Zip Code Ceagj►1g
(3( 36) 957-6030 Iti Oc l ;WR Section
Area code-Phone number
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 205 4 GPM 120- 124 6 GPM 186- 187
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOX]
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c. WATER LEVEL Below Top of Casing: FT. I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
(Use"+"if Above Top of Casing) 15A NCAC 2C,WELL CONSTRUC ON STANDARDS,AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED THE 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 CERTIFIED WELL CONTRAC OR DATE
10 Air KEITH PRESNELL !
e. YIELD(gpm): METHOD OF TEST
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

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