GW1-2021-01354_Well Construction - GW1_20210329

STATEu
Q RESIDENTIAL WELL CONSTRUCTION RECORD
r North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 2780 2002M
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 64
KEITH PRESNELL g. WATER ZONES(depth):
Well Contractor(Individual Name) From 120 To121 From 307To 308
DEWEY WRIGHT WELL&PUMP CO., INC.
From To Frol To
Well Contractor Company Name From To From To
STREET ADDRESS p•O.BOX 308 6.CASING: Thickness/
BOONS NG 28607 Depth Diameter Weight Material
From 0 To 105 Ft. A 114 .188 GAT V
City or Town State Zip Code From To Ft.
( 828 )-264-2651 From To Ft.
Area code-Phone number
7.
2.WELL INFORMATION: GROUT. Depth Material Method
From 0 Tom Ft.$ENTONn amitvFI17N
SITE WELL ID#(if applicable) From.---_ _TO Ft. 28BAGS
STATE WELL PERMIT#(IT applicable) From To Ft.
DWO or OTHER PERMIT#(rtapplicable) 131514 S.SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply lB From To Ft. in. _in.
DATE DRILLED 3/19=1 From To Ft. in. in.
TIME COMPLETED 03:00 AM❑ PM 04 From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
SUGAR GROVE Wlue811a Depth Size Material
CITY: COUNTY From To Ft.
OFF PHI=BRANCH OFF BBTHAL RD OFF HWY From _To Ft. _
From To Ft. _
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
❑Slope ❑valley ❑Flat ❑Ridge ❑Other From To Formation Description
(check appropriate Fax) 0 93 GRAVELIDIRT
May lx in degrees,
LATITUDE 3 minutes,seconds or 23 110 BLUF°GRANITE
LONGITUDE in a decimal format 110 120 BROWN SHELL
Latitude/longitude source: L (GPS ❑Topographic map 120 121 CREVICE
(location of well must be shown on a USGS topo map and 121 307 GRAY&BLUE GRANII
attached to this form if not using GPS) 307 3W CREVICE
4.WELL OWNER 30B 325 GRAY GRAN ITE
OWNER'S NAMEMICHABT &-TSSA SUGGS
STREET ADDRESS6852 TOM ST. � �!
FORT HOOD TX 76544
City or Town State Zip Code
t (8= I- 773-6575 MA
Area code-Phone number
5.WELL DETAILS: 11.REMARKS: Diieii 3;'inil
a. TOTAL DEPTH: 325 1 GPM 120- I'M 29 GPM 3W-309
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO J0
c. WATER LEVEL Below Top of Casing: 20 FT. I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
(Use"+"if Above Top of Casing) 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
RECORD HAS B N PROVlDBEqOTHE WELL OWNER.
d. TOP OF CASING IS 1 FT Above Land S
'Top of casing terminated aV require below land surface may require `,
a variance in accordance with 15A NCAC 2C.0118 SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): 30 METHOD OF TEST Air Tu PDCanF1=1 I
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days.Attn: Information Mgt., Form GW-ta
1617 Mail Service Center- Raleigh,NC 27699-1617 Phone No. [phone] ext 568. Rev.7/05