GW1-2022-10709_Well Construction - GW1_20221205

+ RESIDENTIAL WELL CONSTRUCTION RECORD
x North Carolina Department of Environment and Natural Resources-Division of Water Quality
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WELL CONTRACTOR CERTIFICATION# 2780 1 2,20205
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1.WELL CONTRACTOR: f. DISINFECTION:Type IHTH Amount 38
KEITH PRESNELL g, WATER ZONES(depth):
Well Contractor(Individual)Name From 80 To 81 From 168 To 169
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_4O_Ft. 6 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#(ifapplicable) From To IFt 19-BAGS
WELL CONSTRUCTION PERMIT#140320 From To i Ft.
OTHER ASSOCIATED PERMIT#(if applicable) 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply K From To Ft: in. in.
DATE DRILLED 11/22/2022 From To Ft. in. in.
TIME COMPLETED_03:00 AM O PM OX From To Ft. in. in.
4.WELL LOCATION: 10.SAND/GRAVEL PACK:
CITY: JEFFERSON COUNTY ASHE Depth Size Material
From To Ft.
208 JH BARE DR OFF EARL SHEETS RD OFF HW) 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 11.DRILLING LOG
(check appropriate box)
May be in degrees, From To Formation Description
LATITUDE __ 36.38070N minutes,seconds or 0 23 DIRT
LONGITUDE 81.36711 W in a decimal format 23 80
80 81 QUARTZ .
Latitude/longitude source: X GPS 0 Topographic map 81 168 GRANITE -_v" V 4—
(location of well must be shown on a USGS topo map and 168 169 VOID
attached to this form ifnot using GPS) 169 205 GRANITE,
5.WELL OWNER" I OWNER'S NAME HUGH DONOUR I Of Firm,i a=o
_ �'� PJ Uri
STREET ADDRESS 208 JH BARE DR ~ .Q uJ
JEFFERSON NC 28640 - -
City or Town State Zip Code
33( 6 )- 982-7664
Area code- Phone number 12. REMARKS:
5 GPM 80-81
6.WELL DETAILS: 25 GPM 168-169
a. TOTAL DEPTH: 205
b. DOES WELL REPLACE EXISTING WELL? YES 0 NOX 1 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: 25 FT. RE RD HAS BEEN PROVIDEDHE WELL�OWNER. J
(Use"+"if Above Top of Casing) C�j
d. TOP OF CASING IS 1 FT.Above Land Surface'
'Top of casing terminated at/or below land surface may require SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
a variance in accordance with 15A NCAC 2C.0118. KEITH PRESNELL
e. YIELD(gpm): 30 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 GWAa
1617 Mail Service Center—Raleigh,INC 27699-1617 Phone No.[phone] ext 568. f Rev.3/07
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