GW1-2021-07666_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 j; 210217
WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 49
KEITH PRESNELL
g. WATER ZONES(depth):
Well Contractor(Individual Name From 204 To 206 From 282 To 283
DEWEY GHT YELL &PUMP CO., INC.
From To From To
Well Contractor Company Name From TO From To
STREET ADDRESS P.O.BOX 308 6.CASING: Thickness/
$OONE NC From 0 DTo th 88 Ft D6 118 er 350 Weight pM C rial
City or Town State Zip Code From To Ft.
( 828 ) 26 2651 From To Ft'.
Area code-Phone number 7.GROUT: Depth Material Method
2.WELL INFORMATION:
From To Ft.
- - - -- -_-..0-- - BNTSINIIT
SITE WELL ID#(if applicable) From To Ft.17
STATE WELL PERMIT#(if applicable) From To Ft.
DWO or OTHER PERMIT#(if applicable) 143660 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply® From To Ft. in. in.
DATE DRILLED 10/27/2021 From To Ft. in. in.
TIME COMPLETED 03:00 AM❑ PM T& From To Ft. in. in.
9.SAND/GRAVEL PACK:
3.WELL LOCATION:
Depth Size Material
CITY: GRASSY CREEK COUNTY ASHE From _To Ft.
13696 OLD RVJ Y 16 OFF FRANK H,At,SEY RD OFF H From _To Ft. �'�
From To Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) NOV 16 2r21
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG �+
❑Sloe ❑Valle ❑Flat ❑Ride ❑Other From TO For p'ti�fi�i 1�JIV
p (check appropriate box)g 0 68 OIRT�A r1i,Or)�rC^^tAlr l"'
_ _ 36.552506 May to in degrees,
LATITUDE 3 minutes,seconds or 68 142, GRANITE
LONGITUDE _ _ -81.398353 in a decimal format 142 166 SHALE
Latitude/longitude source: Of GPS ❑Topographic map 166 204 GRANITE
(location of well must be shown on a USGS topo map and 204 206 QUARTZ
attached to this form if not using GPS) 205 282 GRANITE,
4.WELL OWNER 282 283 VOID
OWNER'S NAME SHMDHBAMST CHURCH 283 !W GRANITE
STREET ADDRESSPO BOX 275,
WEST JERFER qON NC 28694
City or Town State Zip Code
(3L 36) )-M-3943
Area code-Phone number
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 305 2 GPM 204-206 18 GPM 292-283
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOXI
60 I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
c. WATER LEVEL Below Top of Casing: 15A NCAC 2C,WELL CONSTRUC N STANDARDS,AND THAT A COPY OF THIS
(Use"t"if Above Top of Casing) RECORD HAS BEEN OVIDED HE WELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land Surface*
'Top of casing terminated at/or below land surface may require IV)/I
a variance in accordance with 15A NCAC 2C.0118 SIGNATURE OF CERTIFIEDWELL CONTRAC R DATE
e. YIELD(gpm): 20 METHOD OF TEST Air KEITH PRESNELL;
PRINTED NAME OF PERSOWCONSTRUCTING 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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