GW1-2022-08808_Well Construction - GW1_20220909

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RESIDENTIAL WELL CONSTRUCTION RECORD
` C North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# ?.7RO 210157
1.WELL CONTRACTOR: If. DISINFECTION:Type HTH Amount d5
KEITH PRESNELL g. WATER ZONES(depth):
Well Contractor(Individual Name) From 287 To 288 From To
DEVVEY'WRiGHT WELL &PUMP CO., INC. From To From TO
Well Contractor Company Name From To From To
STREET ADDRESS F.O.BOX 308 a 6.CASING: Thickness/
BOONE NC 28607 Depth Diameter Weight Material
From Q To i�. Ft. 350 01rc
City or Town State Zip Code From To Ft.
( $2$ )264-2651 From To Ft.
Area code-Phone number
2.WELL INFORMATION: 7.GROUT: Depth Material Method
From_0 To 20 Ft.$E=0b= CC i e,MQW
__SITE-WEL-L-ID-#(tapplicabie) - - ---From - To--- --Ft.j'$${=C- ---- - --
STATE WELL PERMIT#(if applicable) From To Ft.
DWO or OTHER PERMIT#(If applicable) 131497 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply fi7 From To Ft. in. in.
DATE DRILLED 814/2022 From To Ft. in. in.
TIME COMPLETED 03:00 AM❑ PM)iVI From To Ft. in. in.
9.SAND/GRAVEL PACK: '
&WELL LOCATION:
Depth Size Material
CITY: SUGAR GROVE COUNTY WATAUGA From To Ft.
255 FORGET ME NOTS LN OFF OLD 421 OFF 321 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)
May be in degrees,
LATITUDE 3 16 2Fdd19 minutes,seconds or 42 17n EcZ a iIT€
in a decimal format
LONGITUDE itl?2it1 �T�-1F-0 OIIaaT7
Latitude/longitude source: W GPS ❑Topographic map 1-74 287
(location of well must be shown on a USGS topo map and 287 -aa dOIl3
attached to this form if not using GPS)
288 320 CZRANITS
4.WELL OWNER
OWNER'S NAMES 91 TR RRim c7cl DER�c _ _
STREET ADDRESS,* Wn f 2 AI 1 R wnTC i w ^" GIffn
i y or own State - Zip o e S t P 0 R 2027
(0322) )-773-5379
Area code-Phone number lnfcr„ rw F'+ „^:•ming Unit
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 320 7 C19M `��7287-282
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO
AEI
c. WATER LEVEL Below Top of Casing: 100 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 PR ID TOJ>JWELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land Surface* 1
rL/7 VaA
`Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C.0118 SIGNATURE OF CERTIFIED
WEM CONTRA DATE
e. YIELD(gpm): '7 METHOD OF TEST A PRORNIMIIII
--� PRINTED'NAME'O'FPERSM 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,INC 27699-1617 Phone No.[phone] ext 568. Rev.7/05
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