GW1-2021-04562_Well Construction - GW1_20210429

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RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
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WELL CONTRACTOR CERTIFICATION# 2780 200207
1.WELL CONTRACTOR: f. DISINFECTION:Type j HTH
KEITH PRESNELL Amount
g. WATER ZONES(depth):
Well Contractor(Individual Name) From 460 To 461 From To
DEVVEY WRIGHT W&L &PUMP CO., INC.
From To From To
Well Contractor Company Name From To From To
STREET ADDRESS P O.BOX 30$ 6.CASING: Thickness/
BOONE NC 28607 Depth Diameter Weight Material
From 0 To 60 Ft. 61/8 .350 PVC
City or Town State Zip Code From To Ft.
( 828 )-264-2651 From To Ft.
Area code-Phone number
2.WELL INFORMATION: 7.GROUT: Depth Material Method
From 0 To 20 Ft. BFNf ONIT Gravity Flaw
SITE WELL ID#(if applicable) From To Ft.
STATE WELL PERMIT#(if applicable) From To Ft.
DWQ or OTHER PERMIT#(f applicable) 27W4 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply LN From To Ft. in. in.
DATE DRILLED 3/29/2021 From To Ft. in. in.
TIME COMPLETED 03:00 AM❑ PM L From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
CITY:
SUGAR GROVE COUNTY WATAUGA From Depth To Ft. Size Material
OFF RUSH BRANCH OFF BETHEL RD.OFF 321 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
_ _ N 36*17.335 May in degrees, 50 � GRAY GRANITE
LATITUDE 3 minutes,seconds or
LONGITUDE _ W 081+50.995 in a decimal format 460 461 CREVICE
Latitude/longitude source: LIPS ❑Topographic map 461 505 GRAY/OLUE 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 NAME DAMONANDIGNA FICELIN
STREET ADDRESS%DOUG MCGUIR1s CONST., PO BOX 1579
BOONE NC 22607 ..�
City or Town State Zip Code
( (828) )_ 773-30r76 2
Area code-Phone number
S.WELL DETAILS: 11.REMARKS: t,pn Pr��e s
a. TOTAL DEPTH: 505 5 GPM 4W-461 1n��t1�;DWR Sego",
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO�
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c. WATER LEVEL Below Top of Casing: 30 FT. I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
(Use"+"if Above Top of Casing) 15A NCAC 2C,WELL CONSTRUCTION jANDARDS,AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO E ELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land Surface' I ;
Top of casing terminated at/or below land surface may require N1 i -
a variance in accordance with 15A NCAC 2C.0118 SfGNA7MEOF CE IED EL CONTRACTOR DATE
e. YIELD(gpm): 5 METHOD OF TEST KEITH PRESNELL;
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., Form GW-1 a
1617 Mail Service Center-Raleigh, NC 27699-1617 Phone No.[phone] ext 568 Rev.7/05
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