GW1-2021-03289_Well Construction - GW1_20210603

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RESIDENTIAL WELL CONSTRUCTION RECORD
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North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 2790 t M0126
1.WELL CONTRACTOR:
f. DISINFECTION:Type !HTH Amount 171
KEITH PRESNELL g. WATER ZONES(depth):
Well Contractor(Individual Name) From 160 To From 690TO
OEWEY WRIGHT WELL&PUMP CO., INC. From 960 To From To
-
Well Contractor Company Name From To From To
STREET ADDRESS P.0.13OX 308 6.CASING: Thickness/
BOONE NC 2 W7 Depth Diameter Weight Material
From 0 Tom Ft. 6112 .350 PVC
City or Town State Zip Code From To Ft.
( = )-264-2651 From To Ft.
Area code-Phone number 7.GROUT: Depth Material Method
2.WELL INFORMATION: From 0 To 20 Ft.BEN'PONIT GravitvFlava
SITE WELL ID#(ifapplicable) From To Ft. 191RAGS
STATE WELL PERMIT#(if applicable) From To Ft. SELFCERT
DWQ or OTHER PERMIT#(iif applicable) V9T696 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply X From To Ft. in. in.
DATE DRILLED 5/19/2021 From To Ft. in. in.
TIME COMPLETED 03:00 AM❑ PM IN From To Ft. in. in.
9.SAND/GRAVEL PACK:
3.WELL LOCATION:
Depth Size Material
CITY: LWOIR COUNTY CALDWELL From To Ft.
4124 AUSTIN VALLEY DR OFF AUSTIN VALL DR O 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 box) 0 51 SAND/CLAY .
May be in degrees,
LATITUDE 3 minutes,seconds or 51 160 GRANITE-
LONGITUDE in a decimal format 160 160 CREVICE
Latitude/longitude source: �KGPS ❑Topographic map 160 690 GRANITE
(location of well must be shown on a USGS topo map and 690 690 CREVICE
attached to this form if not using GPS) 69D 960 GRANITE
4.WELL OWNER 960 950 CREVICE
OWNER'S NAME THOMAS SAMMIS WD 100D GRANITE
STREET ADDRESS8517 PRESERVE POND RD.
C01Ug1 tUS NC 28031
City or Town State Zip Codenl
( (704) )_ 6W-2063 J`�—/►�
Area code-Phone number information PrCCE;SS
5.WELL DETAILS: 11.REMARKS: [) v KSuv,; T
a. TOTAL DEPTH: 1000 0.25 GPM 160- 0.25 GPM 690-
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO XI 0.5 GPM 9W-
c. WATER LEVEL Below Top of Casing: 60 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 P OVID TO THE WELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land Surface' ♦' �„� ��
'Top of casing terminated at/or below land surface may require J /
a variance in accordance with 15A NCAC 2C.0118 SIGNATURE OF CERTIFIED WELL CONTRA TOR DATE
e. YIELD(gpm): 1 METHOD OF TEST Air KEITH PRESNELL '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-1a
1617 Mail Service Center-Raleigh, NC 27699-1617 Phone No. [phone] ext 566.1 ! Rev.7/05.
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