GW1--04462_Well Construction - GW1_20230710

1
. r RESIDENTIAL WELL CONSTRUCTION RECORD
13 '.e LEd ,g Is. ; North Carolina Department of Environment and Natural Resources-Division of Water Quality
,44 "` WELL CONTRACTOR CERTIFICATION# 2780 230094
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 67
KEITH PRESNELL g. WATER ZONES(depth):
Well Contractor(Individual)Name
From 190 To 220 From 360 To 361
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 0 To 108 Ft. 6 1/6 350 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
From 0 To 20 Ft. BENTONIT GRAVITY
----- -- SITE-WELL-ID#01 applicable)- -- - --- ------- — —
From To Ft. 21 BAGS
WELL CONSTRUCTION PERMIT#368167 From To Ft.
•
OTHER ASSOCIATED PERMIT#(if applicable)
9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply fI( From To Ft. in. in.
DATE DRILLED 6/28/2023 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.
LOT#S15 MONTEAGLE • 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 — — 36.184991 minutes,seconds or 0 96 DIRT
LONGITUDE 81.839221 in a decimal format 96 190 GRANITE
190 220 GREEN GRANITE
Latitude/longitude source: )4 GPS a Topographic map 220 270 GRANITE
(location of well must be shown on a USGS topo map and 270 290 SHALE
attached to this form if not using GPS) 290 360 GRANITE
360 361 VOID I z^'r i .r t,., ,i \'' ."
5.WELL OWNER 361 405 GRANITE B
OWNER'S NAME RICHARD ROEHM n Din
STREET ADDRESS 1680 LAKE DR j,'I N.,
;�t:f::
DEL RAY BEACH FL 33444 =�•• [tea: ,.;t:�:_,3-- i)r'z '
City or Town State Zip Code ilia
(561 )- 252-1913 •
Area code- Phone number 12. REMARKS: •
2 GPM 190-220
6.WELL DETAILS: 18 GPM 360-361
a. TOTAL DEPTH: 405
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 CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
c. WATER LEVEL Below Top of Casing: 80 FT. RECOR HA$$BEEN ROVIDE THE WELL OWNER.
(Use"+"if Above Top of Casing)
d. TOP OF CASING IS 1 FT.Above Land Surface*
'Top of casing terminated at/or below land surface may require SIGNATU E OF CERTIFIED WELL CONTRACTOR DATE
a variance in accordance with 15A NCAC 2C.0118. KEITH PRESNELL
•
e. YIELD(gpm): 20 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. 1 ' - Rev.3/07

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