GW1-2022-02823_Well Construction - GW1_20220224

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RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 2780 210171
1.WELL CONTRACTOR: I
f. DISINFECTION:Type HTH Amount 46
KEITH PRESNELL g. WATER ZONES(depth):
Well Contractor(Individual Name) From 170 To 197 From To
DtW1rEY WRiGH T WELL &.PUMP CO., INC. From -7R3 To )S4 From To
Well Contractor Company Name From To From To
STREET ADDRESS P.O.BOX 308 6.CASING: Thickness/
800NE NC 2$607 Depth Diameter Weight Material
From 0 To_100 Ft. 61/8 350 PVC
City or Town State Zip Code From To Ft.
( 828 )-264-2651 From To Ft.
Area code-Phone number
2.WELL INFORMATION: 7.GROUT: Depth Material Method
From 0 To__20__ Ft.BENTONIT Gray iW Flaw
SITE WELL ID#(if applicable) - From . To Ft:1 2AGS
STATE WELL PERMIT#(if applicable) From To Ft.
DWQ or OTHER PERMIT#(f applicable) 128631 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply From To Ft. in. in.
DATE DRILLED 1/14/2022 From To Ft. in. in.
TIME COMPLETED 03:00 AM❑ PM 10 From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
Depth Size Material
CITY: BOONE COUNTY WATAUGA From To Ft.
143 CINDY RD OFF DBERFIEC.D RD OFF 321 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 91 DIRT
May be in degrees,
LATITUDE 3 36.194066 minutes,seconds or 91 170 GRANITE
LONGITUDE 81.622436 in a decimal format 170 182 QUARTZ
Latitude/longitude source: N GPS ❑Topographic map 182 263 GEANITE
(location of well must be shown on•a USGS topo map and 263 284 QUART7
attached to this form if not using GPS) 284 305 GRANITE
4.WELL OWNER
OWNER'S NAMEZELLY MGDONALD
_ STREET-ADDRES91409 LAKE WALK DR_
PF-GREEbiSBORO NC 27410 "- -'
City or Town State Zip Code
FEB 2 4 `?
r )_719-7000 t
Area code-Phone number
5.WELL DETAILS: 11.REMARKS: WOW
a. TOTAL DEPTH: 305 7.CTpRri 170- 1R2
b. DOES WELL REPLACE EXISTING WELL? YES❑ NV
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c. WATER LEVEL Below Top of Casing: 80 FT. I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
(Use"+"if Above Top of Casing) 15A NCAC 2C,WELL CONSTRUCTI94STANDARDS,AND THAT A COPY OF THIS
REC 0 HAS, 0 ED T E WELL OWNER.
d. TOP OF CASING IS 1• FT Above Land Surface'
Top of casing terminated at/or below land surface may require -h 04&�Q
a variance in accordance with 15A NCAC 2C.0118 SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): 10 METHOD OF TEST Au 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-1 a
1617 Mail Service Center-Raleigh, NC 27699-1617 Phone No. [phone] ext 568.! Rev.7/05
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