GW1-2021-07491_Well Construction - GW1_20211116

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RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
2780 210127
WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: HTH
f. DISINFECTION:Type Amount 69
KEITH PRESNELL
g. WATER ZONES(depth):
Well Contractor(Individual Name) From 330 To 333 From To
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 286M Depth Diameter Weight Material
From 0 To 88 Ft.. 61/8 .350 PVC
City or Town State Zip Code From To Ft.
( M8 )IM-2651 From To Ft.
Area code-Phone number
7.GROUT: Depth Material Method
2.WELL INFORMATION: From 0 To 20 Ft.BENTONPP Gravity Flaw
SITE WELL ID#(if applicable) From TO Ft.20 BAGS
STATE WELL PERMIT#(if applicable) From To Ft.
DWQ or OTHER PERMIT#(if applicable) 234056 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply From To Ft. in. in.
DATE DRILLED 11/1/2021 From To Ft. in. in.
TIME COMPLETED 03•00 AM❑ PM7.43 From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
�F+TEST JEFFFESON p,S� Depth Size Material
CITY: COUNTY From To Ft.
LOT 43 833 RUSTIC RD OFFHARTZOGFORD RD OF 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 79 DIRT
May be in degrees,
LATITUDE 3 36.327618 minutes,seconds or 79 192 GRANITE
LONGITUDE 81.429WI in a decimal format 192 208 SHALE
F
Latitude/longitude source: N GPS ❑Topographic map 208 330 GRANITE
(location of well must be shown on a USGS topo map and 330 333 ! QUARTZ
attached to this form if not using GPS) 333 360 GRANITE
4.WELL OWNER 350 374 SHALE
OWNER'S NAMEROB ZIE NSM 374 420 GRANITE
_.--STREEf ADDRESS160 BONNIE WOODS DR,
GRFEN'VILLE SC 29W5
City or Town State Zip Code
(( WO )_770-5615 P�
Area code-Phone number N O V 16 2071
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 420 1.5 GPM 330-333 DWR SL{ 110N
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO`3 ["'FORMATION PRrC.FSSING UNI"
c. WATER LEVEL Below Top of Casing: 80 FT. I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
(Use"+"if Above Top of Casing) 15A NCAC 2C,WELL CONSTRUCT N STANDARDS,AND THAT A COPY OF THIS
RE HAS BEE P OVIDED T E WELL OWNER.
d. TOP OF CASING IS 1 - FT.Above Land Surface* I 1
*Top of casing terminated at/or below land surface may require — Q I
a variance in accordance with 15A NCAC 2C.0118 SIGNATURE OF CERTIFIEDIWELL CO OR ATE
e. YIELD(gpm): 1.5 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-1 a
1617 Mail Service Center- Raleigh,NC 27699-1617 Phone No.[phone] ext 568: Rev.7/05

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