GW1-2021-07486_Well Construction - GW1_20211116

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RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
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�`� 2780 210129
WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 85
KEITH PRESNELL
g. WATER ZONES(depth):
Well Contractor(Individual Name) From 180 To 182 From 390 To 384
DEWEY'MiGH T 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 2$607 Depth Diameter Weight Material
From 0 To�L Ft. 61/4 .188 GALV
City or Town State Zip Code From To Ft.
( $2$ )-2464-2651 From To Ft.
Area code-Phone number
2.WELL INFORMATION: 7.GROUT: Depth Material Method
From 0 To 15 Ft.BENTONTT Gravity Flow
SITE-WELL ID#(if applicable) - — f��— — - --- Frorrf To --" `--F t:25 BAGS-- -.___-------- ----
STATE WELL PERMIT#(if applicable) From To Ft.
DWQ or OTHER PERMIT#(if applicable) 146216 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply® From To Ft. in. in.
DATE DRILLED 10/26/2021 From To Ft. in. in.
TIME COMPLETED 03:00 AM❑ PM l From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
Depth Size Material
CITY: LANENG COUNTY A`� From To Ft.
LOT 24 OFF BENT RIVER DR BENT RIVET.ESTATES From _To Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) From _To Ft. NOV S 209V
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG ,, nn DWR SECTION
❑Slope ❑Valley ❑Flat ❑Ridge ❑Other From To FormaTion 6Te!b"iipP-FSS)NG UNI
(check appropriate box) 0 9 DIRT/MUD
May be in degrees,
LATITUDE 3 _ 36.310107 minutes,seconds or 9 180 GRANITE
LONGITUDE _ -81.526157 in a decimal format 180 182 QUARTZ
Latitude/longitude source: Q1 GPS ❑Topographic map 182 231) GRANITE
(location of well must be shown on a USGS topo map and 230 282 SHALE
attached to this form if not using GPS) 282 283 QUARTZ.
4.WELL OWNER 283 322 SHALE
OWNER'S NAMEELF"OR EL P= 322 380 GRANITE
STREET ADDRESS332 TURKEY RIDGE RD, -. 380 384 QUARTZ
LA149ING NC 28643 384 425 GRANITE
City or Town State Zip Code
(3( 36) )_877-7148
Area code-Phone number
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 425 1 GPM 180- 182 5 GPM 380-384
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOXI
c. WATER LEVEL Below Top of Casing: 20 FT I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
(Use"t°if Above Top of Casing) 15A NCAC 2C,WELL CONSTRUC N STANDARDS,AND THAT A COPY OF THIS
REC RD HAS BEEN PROVIDE�7
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 CERTIFI WELL C NTRACTOR DATE
e. YIELD(gpm): 6 METHOD OF TEST Air KEITH PRESNELL
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
i
Submit the original to the Division of Water Quality within 30 days.Attn:Information Mgt., Form GW-1 a
1617 Mail Service Center-Raleigh,INC 27699-1617 Phone No.[phone] ext 568J Rev.7/05

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