GW1-2022-09646_Well Construction - GW1_20221021

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4w RESIDENTL4L WELL CONSTRUCTION RECORD
3 ar Q j North Carolina Department of Environment and Natural Resources-Division of Water Quality
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WELL CONTRACTOR CERTIFICATION# 2780 220072
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 14
KEITH PRESNELL g. WATER ZONES(depth):
Well Contractor(Individual)Name From 69 To 72 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/
Depth Diameter Weight Material
BOONE NC 28607 From To_4$_Ft. F 1/4 188 GAI V
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 Ft-140-BAGS—
WELL CONSTRUCTION PERMIT#279795 From To Ft.
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 10/11/2022 From To Ft. in. in.
TIME COMPLETED 03:00 AMU 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.
OFF BALD MTN OFF BALDWIN/CLAR. LYALU221 From To Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) From TO Ft.
TOPOGRAPHIC/LAND SETTING:
0 Slope 0 Valley X Flat 0 Ridge p Other 11.DRILLING LOG
(check appropriate box)
May be in degrees, From To Formation Description
LATITUDE —— 36.37446 minutes,seconds or 0 39 DIRT GRAVEL
LONGITUDE 81.53673 in a decimal format 39 69 GRANITE
— — 69 72 VOID
Latitude/longitude source: X GPS 0 Topographic map 72 105 GRANITE....,,p-•!�,#""ai
(location of well must be shown on a USGS topo map and +'
attached to this form if not using GPS) n r T �I lA
5.WELL OWNER i
OWNER'S NAME MARK&HEIDI WALKER
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STREET ADDRESS 112 WICKHAM SQUARE
BOONE NC 28607
City or Town State Zip Code
(843 )- 252-9695
Area code- Phone number 12. REMARKS:
25 GPM 69-72
6.WELL DETAILS:
a. TOTAL DEPTH: 105
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 CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
c. WATER LEVEL Below Top of Casing: 35 FT. RECORD HAS BEEN PRI11411D D TO WELL OWNER.
(Use"+"if Above Top of Casing) , l 11-e
d. TOP OF CASING IS 1 FT.Above Land Surface*
`Top of casing terminated atlor below land surface may require SIGNATURE OF CERTIFIED W CONTRACT R DATE
a variance in accordance with 15A NCAC 2C.0118. KEITH PRESNELL
e. YIELD(gpm): 25 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 668. Rev.3/07

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