GW1-2023-02822_Well Construction - GW1_20230420

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RESIDENTIAL WELL CONSTRUCTION RECORD
( tjM North Carolina Department of Environment and Natural Resources-Division of Water Quality
°' ^ . WELL CONTRACTOR CERTIFICATION# 2780 220129
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 66
KEITH PRESNELL g. WATER ZONES(depth):
Well Contractor(Individual)Name From 200 To 205 From 370 To 375
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 n To 60 Ft. 6 1/8 350 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. 20 BAGS
WELL CONSTRUCTION PERMIT#161972 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 4-4-2023 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: BANNER ELK couNTY WATAUGA Depth Size Material
From To Ft.
BLADEN RD OFF OLIVER HILL RD. OFF HWY 194 I From To Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) From To Ft. _
TOPOGRAPHIC/LAND SETTING:
0 Slope 0 Valley 0 Flat 0 Ridge 0 Other 11. DRILLING LOG
(check appropriate box)
May be in degrees, From To Formation Description
LATITUDE — — 36.19240N minutes,seconds or 0 54 DIRT
LONGITUDE 81.82015W in a decimal format 54 200 GRANITE
— — 200 205 GRANITE
Latitude/longitude source: X GPS ii Topographic map 205 370 GRANITE
(location of well must be shown on a USGS topo map and 370 375 GRANITE
attached to this form if not using GPS) 375 400 GRANITE
5.WELL OWNER
OWNER'S NAME MICHAEL STEVESON , \„..,,i..:. °.
STREET ADDRESS 411 BLADEN RD
3
BANNER ELK NC 28604 �`�R , Il )I1�
City or Town State Zip Code
( 704 )_ 905-7056
Area code- Phone number 12. REMARKS:
2 GPM 200-205
6.WELL DETAILS: 3 GPM 370-375
a. TOTAL DEPTH: 400
b. DOES WELL REPLACE EXISTING WELL? YES 0 NOD( 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 BEEN PROVIDED TO TJVELL OWNER.
(Use"+"if Above Top of Casing) �- -
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d. TOP CASING IS 1 FT.Above Land Surface*
equi SIGNATURE O E�$II IED WELL CO TRACT DATE
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C.0118. KEITH PRESNELL
e. YIELD(gpm): 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-la
1617 Mail Service Center—Raleigh,NC 27699-1617 Phone No.[phone] ext 568. Rev.3/07

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