GW1-2021-06583_Well Construction - GW1_20211029

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RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 2780 210108
1.WELL CONTRACTOR:
If. DISINFECTION:Type �HTH Amount ?0
KEITH PRESNELL g. WATER ZONES(depth):
Well Contractor(Individual Name) From I I I To,I 1 From To
DEO EY WRiGH T WELL &PUMP CO.. INC. From To From To
Well Contractor Company Name From To From To
STREET ADDRESS P.O.BOX 309 6.CASING: Thickness/
800NE NC 2g60rJ Depth Diameter Weight Material
From 0 To SS Ft. 6 14g _ 310_ IZIC
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.gH=C%= . Oraailu-,,�laaa
SITE WELL ID#i(f applicable)_ From To Ft.IS R C C.0
`STATE WELL PERMIT#(if applicable) From To Ft.
DWO or OTHER PERMIT#(if applicable) 354549 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply W From To Ft. in. in.
DATE DRILLED 10/21/2021 From To Ft. in. in.
TIME COMPLETED 03:00 AM❑ PM KI From To Ft. in. in.
3.WELL LOCATION: 9.SAND/GRAVEL PACK:
Depth Size Material
CITY: LANSING COUNTY ASHE From To Ft.
OFF BEAR WALLOW OFF IAW CRESS'OFF BIG HO 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 0 Ridge ❑Other From To Formation Description
(check appropriate box)
May be in degrees, 0 47 DIRT
LATITUDE 3 36 575RRR minutes,seconds or =47 111 GR Ahl1TzF
LONGITUDE -91 5 Sj577 in a decimal format III 11A 131-IA Z
Latitude/longitude source: LR GPS ❑Topographic map 113 227 RI_I IF 6R ANITE
(location of well must be shown on a USGS topo map and 227 230 RED QUARTZattached to this form if not using GPS) 23 360 RI IJE GRANITE
4.WELL OWNER M 368 13ED QUARTZ
OWNER'S NAMEPETER&DAWN JOHNSON VA A25 811IF GRANITE
STREET ADDRESC/n NINA JOHNSON- 1696 B
LANSING NC 28643
City or Town State Zip Code ,r-
(L507) -512-0809 1Ecl IV
Area code-Phone number q
5.WELL DETAILS: 11.REMARKS: 0
a. TOTAL DEPTH: 425 1 GPM 111 - 113.. Unit
b. DOES WELL REPLACE EXISTING WELL? YES❑ NORI An OTM3tA —
n � !S�II1�
c. WATER LEVEL Below Top of Casing: 80 FT 1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
(Use"+"if Above Top of Casing) 15A NCAC 2C,WELL CON
IN
STANDARDS,AND THAT A COPY OF THIS
RECORD HAS BEEN PROVID T 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 IE T1FIEDF WELL CO1 R DATE
e. YIELD(gpm): 1 METHOD OF TEST Air KEITH PRESNELL
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 568! Rev.7/05
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