GW1-2021-06054_Well Construction - GW1_20211130

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j RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 2780 ` 210110
1.WELL CONTRACTOR:KEITH PRESNELL f. DISINFECTION:Type HTH Amount 120
g. WATER ZONES(depth):
Well Contractor(Individual Name) From 330 To 331 From 673 To 674
DEWEY WRIGHT 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/
BOONE NC 286(Y7 Depth Diameter Weight Material
From 0 To 53 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 53 Ft.CE1E1T PUMPED
SITE-WEL-L-ID-#(if applicable)—_ — From— _—To---Ft. - -- —— -- --- --
STATE WELL PERMIT#(dappiicable) From To Ft.
DWO or OTHER PERMIT#of applicable) 170159 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply From To Ft. in. in.
DATE DRILLED 11/8/2021 From To Ft, in. in.
TIME COMPLETED 0 :00 AM❑ PM 6 From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
Depth Size Material
CITY. BLOVANGROCK COUNTY wda= From To Ft.
495 FAIR PARK DR OFF H'tWY 221 OFF HWY 321BUS 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) 01 45 DIRT
May be in degrees,
LATITUDE 3 _ minutes,seconds or 45= 330 BLUE GRANITE
LONGITUDE _ _ ina decimal format 330 331 CREVICE
Latitude/longitude source: ®GPS ❑Topographic map 331 673 BLUE GRANITE
(location of well must be shown on a USGS topo map and 673 674 I ; CREVICE
attached to this form if not using GPS) 674 700 BLUE GRANITE
4.WELL OWNER
OWNER'S NAMEBILL c$JUDTTH XMMRICK
_STREET_ADDRESSP0 BOX 706, -� -
SANANTONIO FL 33576
City or Town State Zip Code NOV 3
(3( 52) )-346-3WP
Area code-Phone number
5.WELLDETAILS: 11.REMARKS: I,.rf19j1�
a. TOTAL DEPTH:
700 1 GPM 330-331 2 GPM 673 674
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOXI
c. WATER LEVEL Below Top of Casing: 100 FT I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
(Use"+"if Above Top of Casing) 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A PY OF THIS
RECORD HAS BEEN PR IDED E WELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land Surface' O f
"Top of casing terminated at/or below land surface may require7—A ' 6r
a variance in accordance with 15A NCAC 2C.0118 SIGITMKE Z7FrCEA;RfIEDWELL CONTRA T R DATE
e. YIELD(gpm): 3 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-1a
1617 Mail Service Center-Raleigh, NC 27699-1617 Phone No.[phone] ext 568. Rev.7/05

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