GW1-2021-02398_Well Construction - GW1_20210722

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RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 2780 F 2OD245
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 106_.
KEITH PRESNELL g. WATER ZONES(depth):
Well Contractor(Individual Name) Frl7RY HOLE To 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 309 6.CASING: Thickness/
Depth Diameter Weight Material
$OONE NC 28 From To6_ Ft. 614g 1Sn �r4
City or Town State Zip p Code From To Ft.
Areacode-Phone
(g2g—>2�2651 number From To Ft..
2.WELL INFORMATION: 7.GROUT: Depth Material Method
-- - - --From G_To 20 F --_
SITE WELL ID#(if applicable) From To Ftan BA43j
STATE WELL PERMIT#(if applicable) From To Ft.
DWO or OTHER PERMIT#(if applicable) &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply] From To Ft. in. in.
DATE DRILLED Wsr i From To Ft. in. in.
TIME COMPLETED$2.� AM❑ PM ❑ From TO Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
Depth Size Material
CITY:DRY TIME . COUNTY Ulgao„to From _To Ft.
From _To Ft.
351 HERBS HOLLOW RD OFF HERBS HOLLOW OFF 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)
May be in degrees, 0 so
LATITUDE 3 '1j,NP_3�A 5 6- minutes,seconds or so 60 13LUE GRANITE
LONGITUDE in a decimal format 6D 805-, US!IT GRAY GRANITE
Latitude/longitude source: J�GPS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4.WELL OWNER
OWNER'S NAM
STREET ADDRES ,
It ') �p21
I own State NC Zip �l�� P 0t
'1113 1
n rnt;��-�S
�od- o mber i- ,C\l,3'101f sedso
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: anc 0 GPM Eaff HOLE_
b. DOES WELL REPLACE EXISTING WELL? YES❑ NQP
c. WATER LEVEL Below Top Of Casing: 1AA FT. I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
(Use"+"if Above Top of Casi t 5A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
RE OR HA%BfZWPP VIDED TO WELL OWNER.
d. TOP OF CASING IS FT.Above Land Surface`
Top of casing terminated a—ttr below land surface may require a�
a variance in accordance with 15A NCAC 2C.0118 IGNATU E OF C TIFIED WEL CONTRAC DATE
e. YIELD(gpm):_ n� METHOD OF TEST Air
PRIN A 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, NC 27699-1617 Phone No.[phone] ext 568! Rev.7/05
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