GW1-2021-05886_Well Construction - GW1_20211025

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RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: HTH Amount 56
KEITH PRESNELL f. DISINFECTION:Type
g. WATER ZONES(depth):'
Well Contractor(Individual Name) From 162 To 163 From 286 To28B
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 28607 Depth Diameter Weight Material
From 0 To 50 Ft. 6118 .330 PVC
City or Town State Zip Code From To Ft.
( 828 )-264-2651 From To Ft.
Area code-Phone number
_2.WELL INFORMATION:.,__. ` _ _ 7.GROUT: Depth Material Method
_From 0--To —20- Ft;BEN OMT_ GravitV-ZOW--
SITE WELL ID#(if applicable) From To Ft.20 BAGS
STATE WELL PERMIT#(if applicable) From To Ft.
DWQ or OTHER PERMIT#(if applicable) 147145 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply From To Ft. in. in.
DATE DRILLED 10f7/2021 From To Ft'.-in.in. in.
TIME COMPLETED 03:00 AM❑ PM From To Ft. in. in.
9.SAND/GRAVEL PACK:
3.WELL LOCATION:
Depth , Size Material
CITY: CTON COUNTY ASHB From To Ft.
14982 NC HWY 88TET OFF H VY 88167 OFF H{hTY 421 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 42 DIRT
May be in degrees,
LATITUDE 3 36.434157 minutes,seconds or 42 162 GRANITE
LONGITUDE -81.638383 in a decimal format 162 163 QUARTZ
Latitude/longitude source: Of GPS ❑Topographic map 163 245 GRANITE
(location of well must be shown on a USGS topo map and 245 248 SHALE
attached to this form if not using GPS) 248 286. GRANITE
4.WELL OWNER 286 288 QUARTZ _
OWNER'S NAMESHP"ON WOODS 288 305 GRANIIQ G
STREET ADDRESSPO BOX 5
CRESTON NC 28615 nC
City or Town State Zip Code
(8= 406-3411 loat1n=tg WWII
Area -Phone number
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 305 1.5 GPM 162- 163 3.5 GPM 286-288
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO)Q
c. WATER LEVEL Below Top of Casing: 30 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
RR HAS BEEN P VIDED E WELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land Surface'
*Top of casing terminated at/or below land surface may require I 9 I
a variance in accordance with 15A NCAC 2C.0118 SIGNATURE OF CER FIE WELL CONTRACTOR DATE
e. YIELD(gpm): 5 METHOD OF TEST Air KEITH PRESNELL
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
k
Submit the original to the Division of Water Quality within 30 days.Attn:Information Mgt., Form GW-1 a
1617 Mail Service Center-Raleigh,INC 27699-1617 Phone No.[phone] ext 5681 Rev.7/05
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