GW1-2022-02819_Well Construction - GW1_20220224

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RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of W I ater Quality
WELL CONTRACTOR CERTIFICATION# 2790 210M
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1.WELL CONTRACTOR: Amount HTH. - 49
KEITH PRESNELL f. DISINFECTION:Type
g. WATER ZONES(depth)::
Well Contractor(Individual Name) From 270 To 274 From To
D VVEY 11 RiGH T 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/
BOONE NC 2$6QrJ Depth Diameter Weight Material
From 0 To 125 Ft. 61/8 .330 PVC
City or Town State Zip Code From_0 To_ 0 Ft.
( 828 )264-2651 From To Ft.
Area code-Phone number 7.GROUT: Depth Material Method
2.WELL INFORMATION:
From 0 To 20 Ft.BENT ONTT GrayjW Flow.
SITE WELL ID#(If applicable) From To - Ft."2bBAGS` - --
STATE WELL PERMIT#(if applicable) From To Ft.
DWO or OTHER PERMIT#(f applicable) 185133 8.SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply From To Ft. in. in.
DATE DRILLED 1/28/2022 From - To Ft. in. in.
TIME COMPLETED 03:00 AM❑ PM Ill From To Ft. in. in.
3.WELL LOCATION: 9.SAND/GRAVEL PACK:
Depth Size Material
CITY: $GONE COUNTY WATAUCTA From To Ft.
From To Ft.
OFF EAST WEMRD OFF S.MiSALE OFF LWOR 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, Q 117 i 01IRT
LATITUDE 3 461 11 minutes,seconds or 117 172 GRgdUl1:€
LONGITUDE -R17(14S77. in a decimal format 172 196 SHAI E
Latitude/longitude source: IIR GPS ❑Topographic map 196 77n GRANITE
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(location of well must be shown on a USGS topo map and 270 27A QUARTZ
attached to this form if not using GPS) 27A 325 GRANITE
4.WELL OWNER
OWNER'S NAMECAROTINA &S'1'LG'VR M(')RRRG
STREET ADDRESS2489 RUSS COMETT D,
City or Town State Zip Code
( (SM )-964-1809 FEB 2 -
Area code-Phone number
5.WELL DETAILS: 11.REMARKS:
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a. TOTAL DEPTH: ;25 :20 GM-4- 70-274
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOJ]
c. WATER LEVEL Below Top of Casing: 90 FT. I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
(Use"+"if Above Top of Casing) 15A NCAC 2C,WELL CONSTR4&14N STANDARDS,AND THAT A COPY OF THIS
HA)S BE P OVIDE TO; HE WELL OWNER.
d. TOP OF CASING IS 1_ FT.Above Land Surface` [ •��
"Top of casing terminated at/or below land surface may require p(
a variance in accordance with 15A NCAC 2C.0118 SIGNATURE OF CERTIFIED WELL CONTRA TOR DATE
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e. YIELD(gpm): 20 METHOD OF TEST Air
PRINT AM O 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,INC 27699-1617 Phone No.[phone] ext 568. Rev.7/05

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