GW1-2022-01326_Well Construction - GW1_20220124

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RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
�Qu� WELL CONTRACTOR CERTIFICATION# 2780 I j 210213
1.WELL CONTRACTOR:
KEITH PRESNELL f. DISINFECTION:Type iHTH Amount 46
g. WATER ZONES(depth):'
Well Contractor(Individual Name) From 204 To )12 From 230 To260
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 28M Depth Diameter Weight Material
From 0 To 14(5 Ft. d 1/8 .330 PVC
City or Town State Zip Code From To Ft.
( 828 )254-2651 From To Ft.
Area code-Phone number
2.WELL INFORMATION: 7.GROUT Depth Material Method
From 0 To 20 Ft.BENr0141T &avityFlow
SITE WELL ID_#(if applicable)_ From_ To Ft.18 BAGS _
STATE WELL PERMIT#(if applicable) From To Ft.
DWQ or OTHER PERMIT#(if applicable) 1VM01 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply® From To Ft. in. in.
DATE DRILLED 1/6/2022 From To Ft. in. in.
TIME COMPLETED ,03:00 AM❑ PM XJ From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
Depth Size Material
CITY: LENOIR COUNTY CALDVJML From To Ft.
404 W=ING P aW WIldDING CREM WAY VAL 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) 0 138 DIRT.
May be in degrees,
LATITUDE 3 16 06Q914 minutes,seconds or 138 20A GRANITE
LONGITUDE -81,6 1 in a decimal format 204 212 QUARTZ
Latitude/longitude source: W GPS ❑Topographic map 212 230 GRANITE.
(location of well must be shown on a USGS topo map and 230 2W SHALE
attached to this form if not using GPS) 260 305 GRANITE
4.WELL OWNER
OWNER'S NAMEBRIAN FLOOK t
STREET ADDRESsPO BOX 143.
. - LENOIR NC 2M45 JAN 2 4
City or Town State Zip Code
(3( 01) )-991-0031
Area code-Phone number A d
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 305 . 2 GPM 204-212 2 GPM 230-260
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO)p
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 CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDE 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 CERTIFIED!WELL Ot3 R DATE
e. YIELD(gpm): 4 METHOD OF TEST Air KEITH PRESNELL
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
i
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 568� Rev.7/05

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