GW1-2022-09644_Well Construction - GW1_20221021

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RESIDENTIAL WELL CONSTRUCTION RECORD
s g: North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 2780 220018
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 76
KEITH PRESNELL g, WATER ZONES(depth):
Well Contractor(Individual)Name From 184 To 187 From 397 To 398
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/
Depth Diameter Weight Material
BOONE NC 28607 From 0 To_40_Ft. F 1/8 350 PVC
City or Town State Zip Code From To 'Ft.
8( 28 )_264-2651 From To Ft.
Area code- Phone number
2.WELL INFORMATION: 8. GROUT: Depth Material Method
From 0 To 20 Ft. BENTONIT GRAVITY
SITE WELL ID#(if applicable) From-- To - - - C
WELL CONSTRUCTION PERMIT#362820 From To ;Ft. JJ
OTHER ASSOCIATED PERMIT#(if applicable)
9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply ID( From—To—Ft.—in. in.
DATE DRILLED 10/13/2022 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: WEST JEFFERSON COUNTY ASHE Depth Size Material
From To Ft.
10368 NC HWY 163 From To Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) From To Ft.
TOPOGRAPHIC/LAND SETTING:
X Slope 0 Valley 0 Flat 0 Ridge 0 Other
(check appropriate box) 11.DRILLING LOG
May be in degrees, From To Formation Description
LATITUDE — _ 36.07006N minutes,seconds or 0 22 DIRT
LONGITUDE 81.43683W in a decimal format 22 165 GRANITE
— — 165 184 SHALE
Latitude/longitude source: X GPS o Topographic map 184 187 QUARTZ �®
(location of well must be shown on a USGS topo map and 187 310 GRANITE ;� ,
attached to this form if not using GPS)
310 364 SHALE " .Y "
364 397 GRANITE OCT
5.WELL OWNER 397 398 VOID I
OWNER'S NAME AMANDA MITCHELL 398 405 GRANITE
STREET ADDRESS 10368 NC HWY 163 �wf6iFna'an prx3es ]Uri
WEST JEFFERSO NC 28694
City or Town State Zip Code
(540 ' )- 391-1219
Area code- Phone number 12. REMARKS: s� Gem
6.WELL DETAILS: 405 5 C'1�V' � �'% �T Ge �'L "�
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES 0 NOX I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C,WELL CONSTRUCTI TANDARDS,AND THAT A COPY OF THIS
c. WATER LEVEL Below Top of Casing: 20 FT. RjeWRD HAS BEEN PR VIDED TH WELL OWNER.
(Use"+"if Above Top of Casing)
d. TOP OF CASING IS 1 FT.Above Land Surface- v� L 0 to �(
'Top of casing terminated attor below land surface may require SIGNATURE OF CERTIFIED WELL CONTRACT — DATE
a variance in accordance with 15A NCAC 2C.0118. KEITH PRESNELL
e. YIELD(gpm): 50 METHOD OF TEST AIR 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.3/07

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