GW1-2022-03848_Well Construction - GW1_20220331

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RESIDENTIAL WELL CONSTRUCTION RECOIRD
o North Carolina Department of Environment and Natural Resources-Division of Water Quality
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WELL CONTRACTOR CERTIFICATION# 2780 210147
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 92
KEITH PRESNELL g. WATER ZONES(depth):,
Well Contractor(Individual Name) From 660 To 662 From To
DEWEY WRIGHT WELL &PUMP CO., INC.
From To From To
Well Contractor Company Name From TO From To
STREET ADDRESS F.0.BOX 308 6.CASING: Thickness/
BOONE NC 28607 Depth Diameter Weight Material
From To Ft.
City or Town State Zip Code From To Ft.
( us ) 264-2651 From To Ft.
Area code-Phone number
7.GROUT: Depth Material Method
2.WELL INFORMATION: From To Ft.
--`-----SITE-WELL ID-#(f ap iicab7e)— From To --Ff.
---_
STATE WELL PERMIT#oif applicable) From To Ft.
DWO or OTHER PERMIT#oif applicable) 125758 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply From To Ft, in. in.
DATE DRILLED 3/15/2022 From To Ft. in. in.
TIME COMPLETED 03:00 AM❑ PM From To Ft in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
Depth Size Material
CITY.. DRU_LDEE1MR COUNTY AVERY From —TO—;Ft.—
LOT 106 OFF HIGHLAND MIST RD OFF GOLF COUR 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. 6W ORIGINAL WELL
May in degrees, 600 660 OLUE/DARK BLUE GR,
LATITUDE 3 minutes,seconds or
LONGITUDE _ in a decimal format 660 662 QUARTZ/CREVICE
Latitude/longitude source: A GPS ❑Topographic map 662 705 OWE GRANITE
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4.WELL OWNER
OWNER'S NAME DONNA BLACK i 3
_ STREET ADDRESS
BOX 785, _
LTNVILt,B NC 28646 MAR 3 t 2OZ9-
City or Town State Zip Code
( (SM M-2143
Area code-Phone number
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 705 15 GPM 660-662
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOXI
c. WATER LEVEL Below Top of Casing: 250 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, THAT A COPY OF THIS
RECQRD HPS BEEN PRQ4BEB TO T E WELL OW R.
d. TOP OF CASING IS 1 FT.Above Land Surface`
Top of casing terminated at/or below land surface may require A 10
a variance in accordance with 15A NCAC 2C.0118 GNA OF CE I D W L CONTRACTO D
e. YIELD(gpm): 15 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-1 a
1617 Mail Service Center-Raleigh,INC 27699-1617 Phone No.[phone] ext 568. Rev.7/05

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