GW1-2022-10710_Well Construction - GW1_20221205

i
- `, RD I
ESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 2780 1220074
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 85
KEITH PRESNELL g. WATER ZONES(depth):
Well Contractor(Individual)Name From 230 To 275 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 To_a(L__Ft. 6 1/R 11,50_ P\/r
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 I Ft. BENTONIT _GRAVITY
---- -SITE-WELL ID#(if-applicable) — - From Tort. 18 BAGS v
WELL CONSTRUCTION PERMIT#366458 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 IX From—To—Ft.—in. in.
DATE DRILLED 11/21/2022 From—To—Ft.—in. in.
TIME COMPLETED 03000 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.
2981 COX RD OFF BOGGS OFF HWY 163 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
(check appropriate box) 11.DRILLING LOG
May be in degrees, From To Formation Description
LATITUDE __ 36.36668N minutes,seconds or 0 49 DIRT i
81.41480W in a decimal format 49 196 GRANITE
LONGITUDE_ _ 196 230 SHALE
Latitude/longitude source: X GPS 0 Topographic map 230 275 GRANITE
(location of well must be shown on a USGS topo map and 275 290 GRANITE QUARTZ MIX
attached to this form if not using GPS) 290 355 GRANITE
355 390 SHALE :
5.WELL OWNER 390 505 GRANITE
OWNER'S NAME ROBERT GRESHAM I
STREETADDRESS 5909 SPRING VIEW TRAIL
-DURHAM NC 27705
City or Town State Zip Code _
(919 )_ 971-7779 DEC -S 202
Area code- Phone number 12. REMARKS:
2 GPM 230-275 jjnU
8.WELL DETAILS:
a. TOTAL DEPTH: 505
I
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 CONSTRl1C ON STANDARDS,AND THAT A COPY OF THIS
c. WATER LEVEL Below Top of Casing: 100 FT. RE D HAS BEEN PROVIDE,T THE WELL OWNER.
(Use"+"if Above Top of Casing) �
d. TOP OF CASING IS 1 FT.Above Land Surface' /
"Top of casing terminated attor below land surface may require SIGNATURE OF RTIFI ELL CO RAT R DATE
a variance in accordance with 15A NCAC 2C.0118. KEITH PRESNELL
I
e. YIELD(gpm): 2 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,INC 27699-1617 Phone No.[phone] ext 568. Rev.3/07
I

. " ✓ �: 16 ,
CIS
1
SOV
de
-
,�---�_