GW1-2021-02400_Well Construction - GW1_20210722

i
d�.i STATF o i I
RESIDENTIAL WELL CONSTRUCTION RECORD
I
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 2780 ! i =13
i
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 54
KEITH PRESNELL g. WATER ZONES(depth):
Well Contractor(Individual Name) From 117117 Tbi jS From ')AA Tcmp
DEWEY WRIGHT VVELL&PUMP CO., INC. From To From To
Well Contractor Company Name From TO From To
STREET ADDRESS P n RQx 308 6.CASING: Thickness/
Depth Diameter Weight Material
BOONE NC 2MM From 0 Tom}_ Ft; 614 _ 350— IZjC
City or Town State Zip Code From To Ft.
( SnR ) From To Ft'.
Area code- one number TGROUT: Depth Material Method
2.WELL INFORMATION:
_ ----- _ — -- --- -From - 0 To- =-Ft
SITE WELL ID#(if applicable) From To FtAr B A rm-o
STATE WELL PERMIT#(if applicable) From To Ft.
DWQ or OTHER PERMIT#(Iif applicable) 140055 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply)l From To Ft. in. in.
DATE DRILLED From To Ft. in. in.
TIME COMPLETED n3:00 AM❑ PMAU From To Ft: in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
Depth Size Material
CITY:B(ONE COUNTY WataInlsl,� From _To Ft.
From _To Ft.
OFF EAST RIVERS EDGE OFF TVAN RIVERS OFF H 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 DIRT
LATITUDE 3 361 minutes,seconds or 90 117 RI I IF GRAMITF
LONGITUDE 91.951956 in a decimal format 11 118 GRLMrF
Latitude/longitude source: I GPS ❑Topographic map ..a LIGHT BLUE GRANITE
(location of well must be shown on a USGS topo map and Q IARTZIGREf IGE,
attached to this form if not using GPS) GYI
4.WELL OWNER
OWNER'S NAM�]WF-&DE*MTRAG"
STREET ADDRES�e TRUE WORMI ES F1170CAROU E �;
State NG Zip ' %�
er e-* fflm er
'^Tlr3� ' Y ' f1
v
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 305 ! GPM 114 118 49 GPM 2M290
-
b. DOES WELL REPLACE EXISTING WELL? YES❑ NV
i
c. WATER LEVEL Below Top of Casing: 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 C PY OF THIS
RECORD HAS BEEN PROVIDED T E WELL OWNER.
d. TOP OF CASING IS FT.Above Land Surface' — /PA
"Top of casing terminated a or below land surface may requiref4 ( Q v
a variance in accordance with 15A NCAC 2C.0118 SIGNATLIFTE OF CERTIFIED WELL CON' EIATE
i .
r ,
e. YIELD(gpm): SO. - METHOD•OF TEST Air SIT{-i PRFGNFI I •'.-i
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days.Attn:Information Mgt., i Form GW-1a
1617 Mail Service Center-Raleigh,NC 27699-1617 Phone No.[phone] ext 568.r i Rev.7/05
I.
p i
i
E
}

,
�148
Or
:.leap Tilfzd 0f,
Ic
X
'Ed.,
F:4;d2 C�.$tot
'
,AMD'S ETl-
ZOE
.,� r