GW1-2022-10003_Well Construction - GW1_20221104

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• y: RESIDENTML WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division ofi Water Quality
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` R•+ WELL CONTRACTOR CERTIFICATION# 2780 .200220
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 128
KEITH PRESNELL g, WATER ZONES(depth):
Well Contractor(Individual)Name From 568 To 580 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 �—Ft.From To Fi 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 !Ft. 18 BAGS
WELL CONSTRUCTION PERMIT#AG WELL 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 10/27/2022 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: FLEETWOOD COUNTY ASHE Depth Size Material
From To Ft.
6248 RAILROAD GRADE RD OFF BROWNWOOD C From To Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Cade) From To Ft.
TOPOGRAPHIC/LAND SETTING:
0 Slope 0 Valley X Flat 0 Ridge 0 Other 11. DRILLING LOG
(check appropriate box)
May be in degrees, From To Formation Description
LATITUDE _ _ 36.19530N minutes,seconds or 0 50 DIRT
81.33831 W in a decimal format
LONGITUDE_ _ 50
170 196 SHALE '� 6..s _~s �
Latitude/longitude source: X GPS o Topographic map 196 230 pt
SHALE
(location of well must be shown on a USGS topo map and 230 370 GRANITE 2�22
attached to this form if not using GPS) 370 396 SHALE
5.WELL OWNER 396 568 GRANITE
568 580 SHALE twin 11F C:t r,�; ��UjIft
OWNER'S NAME STEPHEN WATSON 580 890 GRANITE J u
STREET ADDRESS 100 FRIENDSHIP RD 890 920 SHALE920 1005 GRANITE
EATONTON GA 31024
City or Town State Zip Code -.
(706 ` )- 484-2477
Area code- Phone number 12. REMARKS:
1 GPM 568-580
6.WELL DETAILS:
a. TOTAL DEPTH: 1005 i
b. DOES WELL REPLACE EXISTING WELL? YES O 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: 350 FT. RECORD HAS BEE PROVI0,FBIO THE WELL OWNER.
(Use"+"if Above Top of Casing) ) /�l.l I �Z I
d. TOP OF CASING IS 1 FT.Above Land Surface' U _ 0ij _ Q 3) ~
'Top of casing terminated at/or below land surface may require SIGNATURE ERT IED WELL C-09 OR 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
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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. I I Rev.3/07
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