GW1-2021-05905_Well Construction - GW1_20211025

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RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
2780 I ! U0102
WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 98
KEITH PRESNELL
g. WATER ZONES(depth):
Well Contractor(Individual Name) From 323 To 324 From 687 To 688
DEVVEY 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 286(Y7 Depth Diameter Weight Material
From 0 To 106 Ft. 61/8 .350 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*
-BENTONIT Gravity-Flow --
SITE WELL ID#(if applicable) From To Ft.22RAW
STATE WELL PERMIT#(if applicable) From To Ft.
DWQ or OTHER PERMIT#(if applicable) ACT WELL &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply From To Ft. in. in.
DATE DRILLED 10/4/2021 From To Ft. in. in.
TIME COMPLETED AM❑ PM U From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
Depth Size Material
CITY: AGWELL, COUNTY CA WELL From To Ft.
OFF LOST RIDGE RD OFF SA10SON RD OFF BLUE 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 95 DIRT
May be in degrees,
LATITUDE 3 36.131537 minutes,seconds or 95 323 GRAY GRANITE
LONGITUDE _ -81.532269 in a decimal format 323 324 QUARTZ/CREVICE
Latitude/longitude source: A GPS ❑Topographic map 324 687 BLUE GRANITE
(location of well must be shown on a USGS topo map and 687. 688 SMALL CREVICE
attached to this form if not using GPS) 688 69D BLUE GRANITE
4.WELL OWNER
OWNER'S NAMECLARISSA SASLOVSKY
STREET ADDRESS7351#Z ROAD
HOVMY IN THE HIT T C FL 34737
City or Town State Zip Code nC
Nil
(3( 52) )-978-0957 -moessina L116ft
Area code-Phone number Infol all", n
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 690 0.5 GPM 323-324 0.5 GPM 6987-688
b. DOES WELL REPLACE EXISTING WELL? YES❑ N0163
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c. WATER LEVEL Below Top of Casing: 200 FT. I DO HEREBY CERTIFY THAT THIS L WAS CONSTRUCTED IN ACCORDANCE WITH
(Use"+"if Above Top of Casing) 15A NCAC 2C,WELL CONSTRUCI ON STANDARDS,AND THAT A COPY OF THIS
RECORD HAS BEEN F.04 IDED OUT WELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land Surface' )
'Top of casing terminated at/or below land surface may require (/
a variance in accordance with 15A NCAC 2C.0118 SIGNATURE OF CERTIFIED VqELL CONTRACTM DATE
e. YIELD(gpm): 1 METHOD OF TEST Air KEITH PRESNELL
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-1 a
1617 Mail Service Center- Raleigh, NC 27699-1617 Phone No.[phone] ext 568.1 Rev.7/05

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