GW1-2021-03203_Well Construction - GW1_20210625

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RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: f. DISINFECTION:Type IHTH Amount 107
KEITH PRESNELL ;
g. WATER ZONES(depth):; '
Well Contractor(Individual Name) From 300 To 301 From 442 To 445
DEWEY WRiGH T NYELL&PUMP CO., INC. From To From To
Well Contractor Company Name From To From To
STREET ADDRESS P.O.BOX 308 6.CASING: Thickness/
BOONE NC 286M Depth Diameter Weight Material
From 0 To 80 Ft. 61/8 .350 PVC
City or Town State Zip Code From To Ft.
( 828 )-264-2651 From To Ft.
Area code-Phone number 7.GROUT: Depth Material Method
2.WELL INFORMATION: From 0 To 20 =Ft!BENTONIT GraviwFlow
SITE WELL ID"#(if apPiioabie)--,-_ --- - —--- _- ------- - --- Fi=om
19BAGS----------- —---
STATE WELL PERMIT#(if applicable) From To Ft!
DWQ or OTHER PERMIT#(rfappiicable) WSW &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply From To Ft in. in.
DATE DRILLED 6/1612021 From To Ft. in. in.
TIME COMPLETED 03:00 AM❑ PM l From To Ft. in. in.
9.SAND/GRAVEL PACK:
3.WELL LOCATION:
Depth Size Material
CITY. IAM MZG CP COUNTY VqMLM From--To Ft.
OFF MY ADD OFF HWY 16 OFF 163 OFF IDLEWIL From _To Ff.
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 box) 0 70 CLAY
May be in degrees,
LATITUDE 3 _ N36*M.817 minutes,seconds or 70 am GRANITE -
LONGITUDE W081;42.610• in.a decimal format 300 301 CREVICE-
Latitude/longitude source: 01 GPS ❑Topographic map 301 440 GRANIITE1WHITE_QUA
(location of well must be shown on a USGS topo map and 440 442 QUARTZ
attached to this form if not using GPS) 442 445_ CREVICE
4.WELL OWNER 445 600 BLACK GRANIT .
OWNER'S NAMES=&DORIS COTE I �'
STREET ADDRESSPO BOX 1006, --- -
MONROE NC 28111 J
City or Town State Zip Code ry.,,,eacRtRQ t111
(_(7�_577-3813
Area code-Phone number
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 600 1.5 GPM 300-301 5.5 GPM 442-445
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO)(j
c. WATER LEVEL Below Top of Casing: 90 FT. I DO HEREBY CERTIFY THAT THIS WELLIWAS CONSTRUCTED IN ACCORDANCE WITH
(Use"+"if Above Top of Casing) 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land Surface* I - /, �� /
*Top of casing terminated at/or below land surface may require _ `f'
a variance in accordance with 15A NCAC 2C.0118 SIGNATURE OF CERTIFIED LL CONTRACTOR DATE
e. YIELD(gpm): 7 METHOD OF TEST Air KEITH PRESNELL -1
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days.Attn: Information Mg't.,� Form GW-1 a
1617 Mail Service Center-Raleigh,NC 27699-1617 Phone No.[phone] ext 568. Rev.7/05
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