GW1-2021-06601_Well Construction - GW1_20211007

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RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
a
`Lam• WELL CONTRACTOR CERTIFICATION# 7780 210164
1.WELL CONTRACTOR: f. DISINFECTION:Type I HTH Amount 69
KEITH PRESNELL
g. WATER ZONES(depth)'.
Well Contractor(Individual Nam2) From 200 To 201 From 325 To 327
DEWEY WRiGHT WELL &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 286W Depth Diameter Weight Material
From 0 To 26 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 BENTONTT GravltgFlow
_. SITE WELL ID#(if-applicable) — _, __ __---From--- To Ft-- —- — --- - -
STATE WELL PERMIT#(if applicable) From To R.
DWQ or OTHER PERMIT#(if applicable) 141970 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable licable Box): Residential Water Supply From To Ft. in. in.
$
DATE DRILLED From To Ft. in. in.
TIME COMPLETED AM❑ PM From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
Depth Size Material
CITY. FLEETWOOD COUNTY ASM From To Ft.
461 WOODSTOWN RD OFF WOODSTOWN RD OFF H 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 5 DIRT
May be in degrees,
LATITUDE 3 _ 36.333537 minutes,seconds or 5 10 CLAY
LONGITUDE _ M. 2,545 in a decimal format 10 25 ROCKIGRANITE
Latitude/longitude source: LN GPS ❑Topographic map 25 200 GRANTE
(location of well must be shown on a USGS topo map and 200 201 . CREVICE
attached to this form if not using GPS) 201 325 GRANITE
4.WELL OWNER 325 327 CREVICE'
OWNER'S NAMEROBERTO MENJIVAR HBRNADES/PATF 327 400 GRANITE
STREET ADDRESS461 WOODSTOWN RD.
FLEETWOO - - _ NC. 28626
City or Town State Zip Code Tfc ,0
3((_ 36) 620-2079 �6
Area code-Phone number
SWELL DETAILS: 400 11.REMARKS:
a. TOTAL DEPTH: GPM 200-201 9 GPM 325-327
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO)b
60
c. WATER LEVEL Below Top of Casing: 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
RE HAS BEEN P VIDE THE WELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land Surface'
Top of casing terminated at/or below land surface may requireE&QA 4/Z/—
a variance in accordance with 15A NCAC 2C.0118 SIGNATURE OF CERTIFIED WELL CONITRACTOR DATE
10 Air KEITH PRESNELL
e. YIELD(gpm): METHOD OF TEST
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] e)t 568.( Rev.7/05
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