_Well Construction - GW1_20230310 (68)

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r'Y `�•' RESIDENTIAL WELL CONSTRUCTION RECORD •
i= o North Carolina Department of Environment and Natural Resources-Division of i Water Quality
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,rtw'' • WELL CONTRACTOR CERTIFICATION# 2780 220109
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 121
KEITH PRESNELL g. WATER ZONES(depth):
Well Contractor(Individual)Name From 240 To 265 From 590 To 620 .
DEWEY WRIGHT WELL&PUMP CO., INC From To From To .
Well Contractor Company Name From To From Tb
STREET ADDRESS PO BOX 308 7. CASING: Thickness/
Depth Diameter Weight Material
BOONE NC 28607 From 0 To 1?7 Ft. 6 1/6 3.50 PVC
City or Town State Zip Code From To Ft.
(828 )-264-2651 _ From To Ft.
Area code- Phone number
2.WELL INFORMATION: 8. GROUT: Depth Material Method
- - " SITE WELL ID`#(if applicable) From 0 To 20 Ft. BENTONIT GRAVITY
From To Ft. 19 BAGS
WELL CONSTRUCTION PERMIT#195906 From To Ft.
OTHER ASSOCIATED PERMIT#(if applicable)
9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply X From To Ft. in. in.
DATE DRILLED 2/27/2023 From To Ft. in. in.
TIME COMPLETED 03:00 AM 0 PM OX From To Ft. in. in.
4.WELL LOCATION: 10.SAND/GRAVEL PACK:
CITY: LANSING COUNTY ASHE Depth Size Material
From To Ft.
SWANSIE SHEPHERD OFF JACK JONES OFF JOE 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 0 Other
(check appropriate box) 11. DRILLING LOG
May be in degrees, From To Formation Description
LATITUDE — — 36.51198N minutes,seconds or 0 116 DIRT
LONGITUDE 81.56616W in a decimal format 1 116 220 GRANITE
— — - 220 240 SHALE
Latitude/longitude source: X GPS 0 Topographic map 240 265 GRANITE QUARTZ
(location of well must be shown on a USGS topo map and 265 380 GRANITE
attached to this form if not using GPS) 380 410 SHALE
410 590 GRANITE
5.WELL OWNER 590 620 GREEN GRANITE
OWNER'S NAME JANET SWAYSLAND% PHIPPS CON 620 705 GRANITE
425 COLFRANCIS RD ',
STREET ADDRESS j�>; ;-''V _r.--r. _ -'
CRUMPLER NC 28617
City or Town State Zip Code MAR 5 0 2023
(336 )- 467-4141 _
Area code- Phone number 12. REMARKS: Lt=- ir- =n Pro•:.a'.:-:`'�`''-)t'l''t
.5 GPM 240-265 C;'d%;u'3:1='
6.WELL DETAILS: 1 GPM 590-620
a. TOTAL DEPTH: 705
b. DOES WELL REPLACE EXISTING WELL? YES 0 NON I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C,WELL CONSTRUC N STANDARDS.AND THAT A COPY OF THIS
C. WATER LEVEL Below Top of Casing: 100 FT. RECOR HAS BEEN P OVIDE4 • HE WELL OWNER.
(Use"+"if Above Top of Casing) V I
l 3-6-�Qa 3
d. TOP OF CASING IS 1 FT.Above Land Surface'
*Top of casing terminated at/or below land surface may require SIGNATURE OF -TIFIED'IVELL CONTRA OR DATE
a variance in accordance with 15A NCAC 2C.0118. KEITH PRESNELL
e. YIELD(gpm): 1.5 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-1 a
1617 Mail Service Center—Raleigh,NC 27699-1617 Phone No.[phone] ext 568. Rev.3/07

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