GW1-2022-08670_Well Construction - GW1_20220419

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RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
2780 210248
WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: HTH
KEITH PRESNELL f. DISINFECTION:Type Amount 49
g. WATER ZONES(depth)': .
Well Contractor(Individual Name) From 195 To 202 From 291 To 292
OEWEY WRIGHT WELL &PUMP CO., INC.
From To From To
Well Contractor Company Name From To From To
—
STREET O.BOX 308
STREET ADDRESS 6.CASING: Thickness/
BOONE NC 28607 From �Depth
85 Ft. Diameter eight Material
0 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 20 Ft.BENTONIT Gravity Flow
- - 0$AGS
SITE WELL ID#(it applicable) From To Ft.
STATE WELL PERMIT#(if applicable) From To Ft.
354446
DWQ or OTHER PERMIT#(if applicable) �c &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply u From To Ft. in. in.
DATE DRILLED yy�� From To Ft. in. in.
TIME COMPLETED AM❑ PM 6 From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
1�j $'SjTT T R �� Depth Size Material
CITY: COUNTY From To Ft.
LOT I CHEROKEE OAKS OFF CFEROKEE OAKS LN 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 40 DIRT
N36*r.634 May in degrees, 40 78 SOFT SHALE
LATITUDE 3 minutes,seconds or '"
LONGITUDE W81*31.527 in a decimal format 78" 195 GRANITE
Latitude/longitude source: LNGPS ❑Topographic map 195 202 QUARTZ,
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(location of well must be shown on a USGS topo map and 202 291 GRANITE
attached to this form if not using GPS) 291 292 VOID
4.WELL OWNER 242 305 G I
OWNER'S NAME �� WHITEHOUSE
STREET ADDRESS°PROTEG, HOLLOW LN
ADVANCE NC 27006 APR 1
City or Town State Zip Code
(3( 36) )- 813-2191 �lBEioo
blNlf� 0C3
Area code-Phone number
SWELL DETAILS: 305 11.REMARKS:
a. TOTAL DEPTH: GPM 95-202 - '35 GPM 291 -292
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO)h
60
c. WATER LEVEL Below Top Of Casing: 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 PRgVIDEIATO THfilyELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land Surface* ) �`
*Top of casing terminated at/or below land surface may require p�
a variance in accordance with-1 5A NCAC 2C.0118 TGNATLTRE OF CERTI D.WEL R DATE
e. YIELD(gpm): 40 METHOD OF TEST Au 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, NC 27699-1617 Phone No.[phone] ext 568., Rev.7/05

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