GW1-2021-03544_Well Construction - GW1_20210607

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RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
2780 210081 __j
WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR:KEITH PRESNELL f. DISINFECTION:Type HTH Amount 150
g. WATER ZONES(depth):
Well Contractor(Individual Name) 777 778
DEWEY WRIGHT WELL&PUMP CO., INC. From To From To
From Tb-i From To
Well Contractor Company Name From To From To
STREET ADDRESS P.O.BOX 30$ 6.CASING: Thickness/
BOONB KC 22607 Depth Diameter Wei' Material
From 0. To 63 Fti 61/4 .188 GALV
City or Town State Zip Code
US 264-2651 From To Ft.
( )- From To Ft.
number Area code-Phone
2.WELL INFORMATION: 7.GROUT: Depth Material Method
From 0 To 63 Ft.CEMENT P[TMPED
- SITE WELL ID#pt applicable)
STATE WELL PERMIT Of applicable) From To Ft.
DWO or OTHER PERMIT#fit applicable)' IW710 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply C From To Ft. in. in:
DATE DRILLED 5/24/2021 From To Ft. in. in.
TIME COMPLETED AM❑ PM From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION: Depth Size Material
CITY: BOONE COUNTY W>tla From To Ft.
3005 SIRR-LS MILL RD OFF SKULLS IAML OFF POP 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 50 ROCKlGRANITE
May be in degrees,
LATITUDE 3 _ minutes,seconds or 50 777 BLUE GRANITE
LONGITUDE in a decimal format 777 778 CREVICE
Latitude/longitude source: 4GPS ❑Topographic map 778 950 GRAY&BLUE GRANIT
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4.WELL OWNER
OWNER'S NAME GAIN
STREET ADDRESS3005 SHULLS MILL RD,
BOONE NC 28607 �"®
City or Town State Zip Code
( (8= -773-9437
Area code-Phone number
;... ��essind Unit
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5.WELL DETAILS: 11.REMARKS: Sec1'on
a. TOTAL DEPTH: 950 1 GPM 777-778.
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOXI
C. WATER LEVEL Below Top Of Casing: 150 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
RECQ2.D HAS BEEN PROV DED T YE 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 CERTIFIE , L CONTRA-C. R 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: Informationf Mgt., % Form GW-1 a
1617 Mail Service Center-Raleigh, NC 27699-1617 Phone No.[phone] ext 568. Rev.7/05
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