GW1-2021-05888_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#
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1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 49
KEITH PRESNELL
g. WATER ZONES(depth):
Well Contractor(Individual Name) From 265 To 268 From 310 To 312
DEWEY WRIGHT WELL&PUMP CO., INC.
From To From To
Well Contractor Company Name From TO From TO
STREET ADDRESS P.0.BOX 308 6.CASING: Thickness/
BOONE NC 28607 Depth Diameter Weight Material
From 0 To 122 Ft. 61/8 .350 13VC
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: -_©To 20 Ft BENTONIT_ Grav_lty_Flcw
SITE WELL ID#(ifapplicable) From To Ft.22BAGS
STATE WELL PERMIT#(if applicable) From To Ft.
DWQ or OTHER PERMIT#(if applicable) 151539 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply From To Ft. in. in.
DATE DRILLED 10/12/2021 From TO Ft. in. in.
TIME COMPLETED AM❑ PM U From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
WAR,RENSViT T F �� Depth Size Material
CITY: COUNTY From To Ft.
462 HARTSOE RD OFF STAGGS CRESKRD OFF HW From _To Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) From To Ft.
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
❑Slope ❑Valley ❑Flat ❑Ridge ❑Other From TO 114 Formation
r ation Description
(check appropriate box)
36.473680 May be in degrees, 114 208 GRANITE
LATITUDE 3 minutes,seconds or
LONGITUDE in a decimal format 208 215 LIMESTONE
I Latitude/longitude source: N GPS ❑Topographic map 215 265 GRANITE
(location of well must be shown on a USGS topo map and 265 258 QUARTZ
attached to this form if not using GPS) 268 310 GRANITE
4.WELL OWNER 310 312 QUARTZ.
OWNER'S NAMEROBERT dt ATHY JOINES 312 325 GRANIT
STREET.l9ppBS
WARRENNC
City or Town State Zip Code —Ui1
(3( 365) 384-3332 - 3 ecessin9
Inform PNAIIR SAC00n
Area code-Phone number
5.WELL DETAILS: 11.REMARKS:
325
a. TOTAL DEPTH: 0.5 GPM 265-268 9.5 GPM 310-312
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO)b
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c. WATER LEVEL Below Top of Casing: 80 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
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aED HE WELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land Surface'Top of casing terminated at/or below land surface may require variance in accordance with 15A NCAC 2C.0118 SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
10 Air KEITH PRESNELL
e. YIELD(gpm): METHOD OF TEST
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
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Submit the original to the Division of Water Quality within 30 days.Attn:Information Mgt., Form GW-1a
1617 Mail Service Center-Raleigh, INC 27699-1617 Phone No.[phone] ext 568.'; Rev.7/05
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