GW1-2022-03857_Well Construction - GW1_20220331

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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# f
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 67
KEITH PRESNELL
g. WATER ZONES(depth);
Well Contractor(Individual Name) From 230 To 235 From 306 To 402
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 NG 28607 Depth Diameter Weight Material
From 0 To 80 Ft. 6118 .350 PVC
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 To_2Q_ Ft.BEN'TONIT Grayfty Flow
SITE WELL ID#if applicable) From TO Ft.
STATE WELL PERMIT#(f applicable) From To Ft.
DWQ or OTHER PERMIT#[•if applicable) 357591 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply 14 From To Ft. in. in.
DATE DRILLED 1/9/2022 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.. BANNEREIZ COUNTY wda= From To Ft.
LOT 19 MONT EAGLE OFF GREAT SKY RIDGE OFF From _To Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) From _To Ft.
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
❑Slope ❑Valley ❑Flat ❑Ridge ❑Other From To Formation Description
(check appropriate box) 0 71 DIRT
May be in degrees,
LATITUDE 3 16.187" minutes,seconds or 71 230 rRANITF
LONGITUDE _ 81,83863W in a decimal format 2,30 235 QUARTZ
Latitude/longitude source: I GPS ❑Topographic map 235 270 GRANITE
(location of well must be shown on a USGS topo map and 270 280 aRFFN rRANITE
attached to this form if not using GPS) 280 2ffi GRANITE
4.WELL OWNER ^285 e02 QUARTZ
OWNER'S NAMETAgQW GROSSMAN 402-425 GRANIXR
--STREET ADDRESS'/RRFAFRiI'K RI.T)r C.ROIIU '2340 R--ANl+lis
BANNEREIR 1417 28ft04 �nnn
City or Town State Zip Code 5� ?
( 004) )-650-5372.
Area code-Phone number
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5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 425 35 9 G-P 396_402
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOil
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c. WATER LEVEL Below Top of Casing: 1lVl 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
RE AS ID D TO EEN PROV IE WEL R.
d. TOP OF CASING IS I FT.Above Land Surface' , 71-
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C.0118 SI NAT F RTI IED L C T
e. YIELD(gpm): 10 METHOD OF TEST
PRINT ':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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