GW1-2021-02421_Well Construction - GW1_20210527

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RESIDENTIAL WELL CONSTRUCTION RECORD
MAY 2 7 2021
North Carolina Department of Environment and Natural Resources-Division of w4pta4M. )'10n Processing Unit
;DWR Section
WELL CONTRACTOR CERTIFICATION# 2780 C' 200rt31
1.WELL CONTRACTOR:
f. DISINFECTION:Type HT1-1�Amount iaT
KEITH PRESNELL g. WATER ZONES(depth):
Well Contractor(Individual Name) From mg To-4n From 66 To "6
DEWEY VAIGHT WELL &PUMP CO., INC. From To From To
Well Contractor Company Name From To From To
STREET ADDRESS p-Cf BOX 3AR 6.CASING: Thickness/
Depth Diameter Weight Material
BOONS NC 2 From To---A Ft. _ 0 �c
City or Town State Zip,Code
Code From To Ft.
( _)- From To Ft:
Area code- one number
7.GROUT: Depth Material Method
2.WELL INFORMATION:
From A TO 20 Ft. 4rn- rGmiwFlow
_
SITE WELL ID#(ifapplicable)--- - __ . . _ - From To - ---_Ft --
STATE WELL PERMIT#(if applicable) From To Ft.
DWO or OTHER PERMIT#(f applicable) 1041 S &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply 4 From To Ft. in. in.
DATE DRILLED silo/ ] From To Ft. in. in.
TIME COMPLETED 03,00 AM Cl PM N From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
Depth Size Material
CITY: 33ANNMEIX COUNTY AVERY From To Ft.
From To Ft.
LOT G-42 OFF SUNRISE COURT OFF LODGE WOOD From To Ft.
(Street Name,Numbers,Communit)4 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 M DIRT
LATITUDE 3 1J7R+11 M-5 minutes,seconds or 22 37 GRAY I IMESTONE
LONGITUDE W(1R1+SS 1ReG in a decimal format 37 105 HARD UMESTQNE
Latitude/longitude source: L*GPS ❑Topographic map 105 470 GREY GRANITE
(location of well must be shown on a USGS topo map and 470--471 CRMnro
attached to this form if not using GPS)
471 -667 i BLUE n_aeettTe
4.WELL OWNER 66 6668 ^QEz_RTZ7xR€MGE
OWNER'S NAME STESqq= Cagg _ISM 7W DARK BLUE GRANITE
STREET ADDRESS%
Iry or own State NC Zip Co e
((910) )- S44-9169 .
Area code-Phone number
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 700 1 GMA 47Q-471 1 GM 60-6&
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOl
C. WATER LEVEL Below Top of Casing: 2W 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 D HE WELL OWNER.
d. TOP OF CASING IS t FT.Above Land Surface* j j
'Top of casing terminated at/or below land surface may require J
a variance in accordance with 15A NCAC 2C.0118 SIGNATURE OF IFIED WELL CON TOR DATE
i
e. YIELD(gpm): 2- METHOD OF TEST Air KEITH PRE,RNFI!I
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days.Attn:Information�M'gt., Form GW-1 a
1617 Mail Service Center-Raleigh,INC 27699-1617 Phone No. [phone] ext 568( Rev.7/05
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