GW1-2022-09921_Well Construction - GW1_20221031

RESIDENTIAL WELL CONSTRUCTION RE C ORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
• >' WELL CONTRACTOR CERTIFICATION# 2780 220036
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 67
KEITH PRESNELL g, WATER ZONES(depth):
Well Contractor(Individual)Name From 365 To 372 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 190 Ft. 61/R 3,90 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
_ __---. --- _ -From To - - � �Ft��19 BAGS
WELL CONSTRUCTION PERMIT#362829 From To Ft.
OTHER ASSOCIATED PERMIT#(if applicable)
9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply 0 From To Ft. in. in.
DATE DRILLED 10/20/2022 From To Ft. in. in.
TIME COMPLETED 03:00 AM O PM OX From To_o Ft. in. in.
4.WELL LOCATION: 10.SAND/GRAVEL PACK:
CITY: LAUREL SPRINGS COUNTY ASHE Depth Size Material
From To I Ft.
LOT#32 FOX CREST OVERLOOK OFF ABSHER OF 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
LATITUDE 36.43048N May be in degrees, From TO Formation Description
— — minutes,seconds or 0 110 DIRT '
LONGITUDE 81.36744W in a decimal format 110 268 GRANITE
— — 268 305 SHALE
Latitude/longitude source: X GPS 0 Topographic map 305 365 GRANITE
(location of well must be shown on a USGS topo map and 365 372 SHALE QUARTZ _ ,.
attached to this form if not using GPS) 372 405 GRANITE ,: t y
5.WELL OWNER I
OWNER'S NAME WAYNE STORM I
STREET ADDRESS 108 DOWNING GROVE CT n� �rw5�S,4F Until
MORRISVILLE NC 27560
City or Town State Zip Code
(919 )- 641-0349
Area code- Phone number 12. REMARKS:
2 GPM 365-372
6.WELL DETAILS:
a. TOTAL DEPTH: 405
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: 80 FT. RECORD HAS BEE O IDEDV WELL OWNER.
(Use"+"if Above Top of Casing) d
•O
d. TOP CASING IS 1 FT.Above Land Surface- SIGNATURE OF C RTIFIE WELL CONT D� ATE
"Topp of casing terminated aUor below land surface may require
a variance in accordance with 15A NCAC 2C.0118. KEITH PRESNELL
e. YIELD(gpm): 2 METHOD OF TEST AIR PRINTED NAME OF PERSON CONSTRUCTING THE WELL
I
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Submit the original to the Division of Water Quality within 30 days. Attn:Information'Mgt., Form GWAa
1617 Mail Service Center—Raleigh,INC 27699-1617 Phone No.[phone] ext 568. Rev.3/07
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