GW1-2022-06390_Well Construction - GW1_20220603

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RESIDENTIAL WELL CONSTRUCTION RECORD
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North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 27$0 I 210199-1
1.WELL CONTRACTOR:
f. DISINFECTION:Type +HTH Amount 23
KEITH PRESNELL
g. WATER ZONES(depth):
Well Contractor(Individual Name) From fit To 97 From 110 To 111
DEWEY VVRIGHT 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/
BOONS NC 286(r1 Depth Diameter Weight Material
From 0 To 22 Ft. 61f8 .350 13VC
City or Town State Zip Code From To Ft.
( = )-264-2651 From To Ft.
Area code-Phone number
2.WELL INFORMATION: 7.GROUT Depth ; Material Method
From 0 To 20 Ft,BENTOIU Gravity Flaw
SITE WELL ID#(if applicable) From To Ft.
BAGS
STATE WELL PERMIT#(if applicable) From To Ft.
DWQ or OTHER PERMIT#(if applicable) 184350 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply From To Ft. in. in.
DATE DRILLED 5125/2022 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: BANNER ELK COUNTY W=igua From _To Ft.
LOT 8 OFF CRAB ORCHARD OFF TOM SHOOK RD O 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 15 DIRT
May be in degrees,
LATITUDE 3 36.189611 minutes,seconds or 15 82 GRANITE
LONGITUDE -81.704577 in a decimal format 82 87 QUARTZ
Latitude/longitude source: ®GPS ❑Topographic map 87 110 GRANITE
(location of well must be shown on a USGS topo map and 110 111 VOID
attached to this form if not using GPS) 111 145 11.T
4.WELL OWNER I '
OWNER'S NAMES PHM11U8 n r N 0 4 2
STREET-ADDRESs/J�IER CONTILkCTING, 2958 ELK_ 0(�v� `
ELK PARK NC W22
City or Town State Zip Code ,1,UN"i
M h,PId
(l 304) )-972-7452vt�trtT=
Area code-Phone number
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 145 5 GPM 82-87 25 GPM 110- 111
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO)]
A"e ctnne
c. WATER LEVEL Below Top of Casing: 30 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
RECORD HAS BEEN PROVIDED T THE WELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land Surface* L y^Q
`Top of casing terminated at/or below land surface may require I d
a variance in accordance with 15A NCAC 2C.0118 IGN RE OFtnPirIFIEDWELL C R DATE
e. YIELD(gpm): 30 METHOD OF TEST Air KEITH PRESNELL
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
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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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