GW1-2022-03851_Well Construction - GW1_20220331

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4 .9 RESIDENTIAL WELL CONSTRUCTION RECORD
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North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 2780 21OMS
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).WELL CONTRACTOR: f. DISINFECTION:Type IHTH Amount U
KEITH PRESNELL g. WATER ZONES(depth):I
Well Contractor(Individual Name)
From at n Tort 1 From To
DEWEY WRIGHT WELL &.PUMP CO., INC. From To From To
Well Contractor Company Name From To From To
STREET ADDRESS P.O.BOX 308 6.CASING: Thickness/
BOONE NC M07 Depth Diameter Weight Material
From 0 Tb_--a Ft. 61IR 3]o )Silt:
City or Town State Zip Code From To Ft.
( 828 )-264-2651 From To Ft.
Area code-Phone number
7.GROUT: Depth Material Method
2.WELL INFORMATION:
From 0 Tom_ Ft.$ �"w-wirvTllcaw
LL SITE WE ID#(if applicable) From To Ft.�$$AGS
STATE WELL PERMIT#(if applicable) From To Ft.
DWO or OTHER PERMIT#of applicable) 1 75766 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply 6] From To Ft. in. in.
DATE DRILLED a12212022 From To Ft. in. in.
TIME COMPLETED,03- 10 AM❑ PM 1 From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
Depth Size Material
CITY: BANNERE-K COUNTY AVERY From To Ft.
From _To Ft.
LOT F-26 EAGLES NEST OFF GREAT M CT OFF HI 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) ft i2 DIRT
May be in degrees,
LATITUDE 3 1621it7JA minutes,seconds or 12 Ain GRAY GRANITE
LONGITUDE -R1 916R7ft in a decimal format Ain 413 rRFVIrF
Latitude/longitude source: IR GPS ❑Topographic map 413—425 1 IMFCTnhIF
(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(gf_AR GnTO
STREET-ADDRES9/e RKY HO 1S .CONSTRUCTION, 1R74 TYN
BANNER ET X NC 2 M4
City or Town State Zip Code ;
( (SM )-773-6668 11 2W
Area code-Phone number
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 425 5(l GMA 41 n-411
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOg]
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 STAND AND THAT A COPY OF THIS
PH S BEEN PROVID TO THE W OW ER.
d. TOP OF CASING IS 1 FT.Above Land Surface* 7
*Top of casing terminated at/or below land surface may require i.
a variance in accordance with 15A NCAC 2C.0118 IGNA U CERTILIED WELL CONTRACTOR
b ':
e. YIELD(gpm): 50 METHOD OF TEST Air F
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,INC 27699-1617 Phone No.[phone] ext 568. Rev.7/05
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