GW1-2022-07081_Well Construction - GW1_20220801

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RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
2780 220049
WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 121
KEITH PRESNELL
g. WATER ZONES(depth):
Well Contractor(Individual Name) From 210 To 222 From 503 T0530
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/
BOONE NC 28607 Depth Diameter Weight Material
From 0 To 86 Ft. 61i8 .350 PVC
City or Town State Zip Code From To Ft.
( SM )264-2651 From To Ft.
Area code-Phone number
2.WELL INFORMATION: 7.GROUT: -Depth Material Method
From 0 To 20 Ft BENTONIT Gravity Flaw
SITE WELL ID#(if applicable) From To Ft.
STATE WELL PERMIT#(if applicable) From To Ft.
DWQ or OTHER PERMIT#(if applicable) 246650 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supplyl l From To Ft. in. in.
DATE DRILLED 7/W2022 From To Ft. in. in.
TIME COMPLETED 03:00 AM❑ PMYU From To Ft. in. in.
9.SAND/GRAVEL PACK:
3.WELL LOCATION R ASHE Depth SizeCRULDLE RR312 ��
CITY: COUNTY From _To Ft.
LOT 63 HIDDEN MTNIN HIDDEN M WE HIDDEN M From _To Ft.
From To Ft. "
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code)
Inifewr;wCion Proeewstrtg I IM
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG DWQ40G
IN Slope ❑Valley ❑Flat ❑Ridge ❑Other From To Formation Description
(check appropriate box) 0 78 DIRT
36.52396N May in degrees, 78 128 GRANITE
LATITUDE 3 minutes,seconds or
LONGITUDE 81.37352W in a decimal format 128 146 SHALE
Latitude/longitude source: 6 GPs ❑Topographic map 146 210 GRANITE
(location of well must be shown on a USGS topo map and 210 222 QUARTZ
attached to this form if not using GPS) 222 360 GRANITE
4.WELL OWNER 360 M SHALE
OWNER'S NAMETEFF'REY DIT= BENNE7 3W 505 GRANITE
STREETADDRES900 RAMBLEWOOD DR, - - 505 sm QUARTZ/GRANITE/MD
RALEIGH NC 27609 530 %0 SHALE
City or Town State Zip Code 5W 705 GRANITE
(9( 19) )_601-0553
Area code-Phone number
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 705 1 GPIA 210-222 1 GPM 505-530
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOU
i
c. WATER LEVEL Below Top of Casing: 100 FT. 100 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 E WELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land Surface' i
"Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C.0118 IGNATURE OF CERTIFIED WE CONTR R DATE
Air
e. YIELD(gpm): 2 METHOD OF TEST 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-1a
1617 Mail Service Center-Raleigh,NC 27699-1617 Phone No.[phone] ext 568. Rev.7/05

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