GW1--04953_Well Construction - GW1_20230807

1.4 ¢ b fES`IDEN DAL WELL CONSTRUCTION RECORD
JisS. North Carolina Department of Environment and Natural Resources-Division of Water Quality ,
• ''' WELL CONTRACTOR CERTIFICATION# 2780 220j123
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 105
KEITH PRESNELL g. WATER ZONES(depth):
Well Contractor(Individual)Name • From 120 To 160 From 510 To 540
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 66 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(D (ifapplicable) From 0 To 20 Ft. BENTONIT GRAVITY
From___ To IFt. 17 BAGS
WELL CONSTRUCTION PERMIT#12072 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 7/14/2023 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: BANNER ELK COUNTY AVERY Depth Size Material
From To Ft.
LOT VRS17 OFF EAGLES NEST OFF HWY 194 OFf 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 — 36.12493 minutes,seconds or 0 52 DIRT
LONGITUDE 81.55733 in a decimbl format 52 120 C RANITE
— — 120 160 QUARTZ
Latitude/longitude source: X GPS o Topographic map 160 330 GRANITE
(location of well must be shown on a USGS topo map and 330 350 SHALE
attached to this form if not using GPS) 350 510 GRANITE
5.WELL OWNER 510 540 SHALE'
540 700 GRANITE L.� e '+ E y
OWNER'S NAME BAKE SHEPHERD • � �—`-'
. STREET ADDRESS 3432 THE PLAZA — -`f-gt73
.. CHARLOTTE NC 28205
. City or Town State Zip Code' It C;r.-a,T.n Prf,c5:y-;3 1..:r17;t
( 704 )_ 910-6445 •
r"9'013 Y
Area code- Phone number 12. REMARKS:
1 GPM 120-160
6.WELL DETAILS: 1 GPM 510 540
a. TOTAL DEPTH: 700
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: 200 FT. RECORD HAS BEEN PROVID O THE WELL OWNER.
(Use"+"if Above Top of Casing) I 17' o=2
d. TOP OF CASING IS 1 FT.Above Land Surface*
*Top of casing terminated at/or below land surface may require SIGNAT RE OF CERTIFIE ELL CONT ACTOR DATE
a variance in accordance with 15A NCAC 2C.0118. KEITH PRESNELL
e. YIELD(gpm): 2 METHOD OF TEST AIR PRINTED NAME OF PERSON CONSTRUCTING THE WELL
;
I I
• Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt., Form GW-1a
1617 Mail Service Center:Raleigh, NC 27699-1617 Phone No. [phone] ext 568. , Rev.3/07

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