GW1-2021-03202_Well Construction - GW1_20210625

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RESIDENTIAL WELL CONSTRUCTION RECORD i{
North Carolina Department of Environment and Natural Resources-Division of Water`Quality
•` �° 2780 f 210103
WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH g. Amount 106
KEITH PRESNELL i
g. WATER ZONES(depth):
Well Contractor(Individual Name) From 450 To 451 From 500 T0705
DEWEY WRIGHT WELL &PUMP CO., INC.
From To From To
Well Contractor Company Name From To I From To
STREET ADDRESS p 0.BOX30$ 6.CASING: Thickness/
BOONS NC 28607 Depth Diameter Weight Material
From To Ft.
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 To Ft.
--- SITE WEL-L-ID-#(ifapplicable)--- ----- — ------- ---- --From-_._..--To---- —Ft.i----- -- - ----- ---
STATE WELL PERMIT#(if applicable) From To Ft.!
DWO or OTHER PERMIT#(if applicable) 359M &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply]a From To Ft. in. in.
DATE DRILLED 6/18/2021 From To Ft.`: in. in.
TIME COMPLETED 03:00 AM❑ POD From To Ft.' in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
DPJIL DEMER Wats=s Depth Size Material
CITY: COUNTY From _To Ft.
1469 DMWYI LD ROAD OFF DEERF=OFF HWY From _To Ft.
From To Ff.
(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) May be in degrees, 0 320 EXISTING WELL
LATITUDE 3 36.1M53 minutes,seconds or 320 450 BLUE GRANITE
LONGITUDE -81.637059 in a decimal format 450 451 i CREVICE
Latitude/longitude source: ®GPS ❑Topographic map 451 5W SWE,GRANITE
(location of well must be shown on a USGS topo map and 500 705 BLUE GRANITE
attached to this form if not using GPS)
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4.WELL OWNER
OWNER'S NAMEIA MSS&PEGGY LYC SS
STREET ADDRESA LYONS.DEN INC. PO BOX 401 --- -- - r
BOONE: 14C. 28607
City or Town State Zip Code jr r SgtO� tll
964-1297• lvoll
Area code-Phone number
5.W ELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 705 1 GPM 450-451 1 C*PtM 500-705
b. DOES WELL REPLACE EXISTING WELL? YES❑ NC)p
C. WATER LEVEL Below Top of Casing: 200 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 BEEN PROVIDE 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
a variance in accordance with 15A NCAC 2C.0118 SIGNATURE OF ERTIFIED WELL CONTRA R DATE
e. YIELD(gpm): 2 METHOD OF TEST Air PRINTED ME OF PERSON CONSTRUCTING THE WELL
is
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.I Rev.7/05
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