GW1-2022-09126_Well Construction - GW1_20220930

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 2780 220099
1.WELL CONTRACTOR: f. DISINFECTION:Typel HTH Amount 128
KEITH PRESNELL g. WATER ZONES(depth):
Well Contractor(Individual)Name From 190 To 230 From To
DEWEY WRIGHT WELL&PUMP CO., INC From To From To
Well Contractor Company Name From To From To
STREET ADDRESS PO BOX 308 7. CASING: Thickness/
BOONE NC 28607 Depth Diameter Weight Material
From 0 To 80 Ft. F 1/8 3.50 PVC;
City or Town State Zip Code From To Ft.
8L 28 )-264-2651 From To Ft.
Area code- Phone number
2.WELL INFORMATION: 8. GROUT: Depth Material Method
SITE WELL ID#(if applicable) -' From 0 To 20 I Ft. BENTONIT GRAVITY
From To Ft. 18 BAGS
WELL CONSTRUCTION PERMIT#374216 From To Ft.
OTHER ASSOCIATED PERMIT#(if applicable)
9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply Ik From To Ft. in. in.
DATE DRILLED 09/21/2022 From To Ft. in. in.
TIME COMPLETED 03:00 AM 0 PM OX From To Ft. in. in.
4.WELL LOCATION: 10.SAND/GRAVEL PACK:
CITY: CRUMPLER COUNTY ASHE Depth Size Material
From To Ft.
OFF HWY 16 OFF HWY 221 OFF HWY 421 From To Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) From To Ft.
TOPOGRAPHIC/LAND SETTING:
0 Slope 0 Valley A Flat 0 Ridge 0 Other
(check appropriate box) 11. DRILLING LOG
May be in degrees, From To Formation Description
LATITUDE _ _ 36.46686N minutes,seconds or 0 3 DIRT
61.39726W in a decimal format 3 15 GRANITE
LONGITUDE_ _ 15 50 DIRT
Latitude/longitude source: X GPS 0 Topographic map 50 60 GRANITE
(location of well must be shown on a USGS topo map and 60 68 DIRT
attached to this form if not using GPS) 68 190 GRANITE p a
5.WELL OWNER 190 230 SHALE r,U 4 U
230 490 GRANITE
OWNER'S NAME THE BROADWAY GROUP 490 548 SHALE CP 2@22
548 610 GRANITE E_T�4 n CC'
STREET ADDRESS PO BOX 18968 610 670 SHALE
HUNTSVILLE AL 35804 670 805 GRANITE ,oT.w UnA
City or Town State Zip Code
2( 56 )_ 929-5877
Area code- Phone number 12. REMARKS:
1 GPM 190-230
6.WELL DETAILS:
a. TOTAL DEPTH: 805
b..DOES WELL REPLACE EXISTING WELL? YES 0 NOR I DO HEREBY CERTIFY THAT THIS,WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
c. WATER LEVEL Below Top of Casing: 150 FT. RECORD HAS B THE WELL OWNER.
(Use"+"if Above Top of Casing) � ' 7R�7o
d. TOP OF CASING IS 1 FT.Above Land Surface*
*Top of casing terminated at/or below land surface may require SIGNATURE O CERTIFIED WELL CONTR R DATE
a variance in accordance with 15A NCAC 2C.0118. KEITH PRESNELL
e. YIELD(gpm): 1 METHOD OF TEST AIR PRINTED NAME OF PERSON CONSTRUCTING THE WELL
i
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.3/07

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