GW1-2022-01423_Well Construction - GW1_20220124

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RESIDENTIAL WELL CONSTRUCTION RECORD
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North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 2780 210165
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 0
KEITH PRESNELL
g. WATER ZONES(depth):!
Well Contractor(Individual Name) FroA$Y HOLE To From To
DEVVEY 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 28607 Depth Diameter Weight Material
From 0 To 100 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_ 20 Ft.BENTONIT Gry im Flaw
-SITE-WELL ID#(ifapplicable) From To Ft.24BAGS _
STATE WELL PERMIT#(if applicable) From To Ft.
DWQ or OTHER PERMIT#(if applicable) 0708W &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply From To Ft. in. in.
DATE DRILLED 1/13/2022 From To Ft. in. in.
TIME COMPLETED 03:00 AM❑ PM KI From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
Depth Size Material
CITY: DRY HOLE COUNTY VJH= From To Ft.
OFF H J Y 421 AT WILKES/tVdATAUGA CO IM From _To Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) From _To Ft.
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
❑Slope ❑Valley ❑Flat ❑Ridge ❑Other From To Formation Description
(check appropriate box) 0 91 DIRT
May be in degrees,
LATITUDE 3 36.7,10363 minutes,seconds or 91 168 GRANITE
LONGITUDE -81.45M2 in a decimal format 168 234 SHALE
Latitude/longitude source: W GPS ❑Topographic map 234 360 GRANITE
(location of well must be shown on a USGS topo map and 360 368 01 IART7
attached to this form if not using GPS)
_SIMI dd1 RRANITF
4.WELL OWNER 441 448 011ART7 '
OWNER'S NAMET ENA T E1T S __148___490
STREET ADDRESS)O BOX IS, 490 5713 t;RANITF
DEEP GAP NC 28619 57n 605 cHAI F
City or Town State Zip Code 605 620 011ART7
(( 8= )-964-2923 620 705 GRANITE
Area code-Phone number
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 705 0 GPM DRY HOLE-
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOS]
c. WATER LEVEL Below Top of Casing: 0 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 PROVID TO 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 IWE[ C CTOR DATE
e. YIELD(gpm): 0 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 5 d8 Rev.7/05

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