GW1-2021-02793_Well Construction - GW1_20210811

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RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
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WELL CONTRACTOR CERTIFICATION# 2780 210M
1.WELL CONTRACTOR:
KEITH PRESNELL f. DISINFECTION:Type HTH Amount 75'
g. WATER ZONES(depth):.
Well Contractor(Individual Name 110 111 355 356
DEWEY W GH T WELL &PUMP CO., iNC . From To From To
From 370 To 37 From To
Well Contractor Company Name From To From To
STREET ADDRESS P O.BOX 30$ 6.CASING: Thickness/
BOONE NC 28607 Depth Diameter Weight Material
From 0 To 60 Ft. (51/8 .350 PVC
City or Town State �4 hU From To Ft.
( 828 )-264-2651 From To Ft.
Area code-Phone number 1 2021
2.WELL INFORMATION: AUC 1 7.GROUT: Depth Material Method
From._:_,...,.,r�,n Pro�essin 0 20 ;BENTONIT GraaityFlow
SITE WELL ID#(if applicable) g I I$ From To Ft.23 BAGS
STATE WELL PERMIT#(if applicable) 6WR SecY'on From To Ft.
DWO or OTHER PERMIT#(if applicable) 329427 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply 01 From To Ft. in. in.
DATE DRILLED 7/2612021 From To Ft. in. in.
TIME COMPLETED AM❑ PM NI From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
Ash,
Size Material
CITY: TODD COUNTY Ashe From To Ft.
OFF LAUREL CREg'OFF HW'Y 194 OPT'HWY 2210 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 5 ROCK-
N36+32.540 May in degrees, 5 55 DIRT/SANDSTONE
LATITUDE 3 minutes,seconds or
LONGITUDE � 4 4 in a decimal format 55 110, GRANITE ,
Latitude/longitude source: NGPS ❑Topographic map 110 111 CREVICE
(location of well must be shown on a USGS topo map and 111 240 GREEN GRANITE ..
attached to this form if not using GPS) 240 355 GRANITE
4.WELL OWNER 355 356 CREVICE
OWNER'S NAME SANDY VIILSON 355 370 GREEN GRANITE
STREET ADDRESS9883 NC HWY.210,_. 370 372 VOID-
ROCKY POINT NC 2$457 372 420 GREEN GRANITE
City or Town State Zip Code
(9( 10) )- 465-6806
Area code-Phone number
5cWELL DETAILS: 11.REMARKS:
•a,,TOTAL'DEPTH: 0.5 GPM 110-ill 4.5 GPM 355-356
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOD 55 GPM 370-37
c. WATER LEVEL Below Top of Casing: 40 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
R OfID HAS E PROVID 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 COI TMOTOR DATE
e. YIELD(gpm): 60 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 568. Rev.7/05

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