GW1-2021-05452_Well Construction - GW1_20210527

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o RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 2780 2002M
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 91
KEITH PRESNELL g. WATER ZONES(depth)'
Well Contractor(Individual Name) From iSS To From 422nTo
-426
DEVVEY WRIGHT VirLL &PUMP CO., INC. From can To From To
Well Contractor Company Name From�P To From To
STREET ADDRESS P_0.BOX 308 6.CASING: Thickness/
Depth Diameter Weight Material
BOONE NC 28607 From 0 To -go- Ft. 6 11a ;338 PVC
City or Town State Zip Code From To Ft.
( _)- 51 From To Ft.
Area code-P�ione number 7.GROUT: Depth Material Method
2.WELL INFORMATION:
From_0 TO 20 Ft.$EMGM GmkyMm_.
SITE WELL ID#(if applicable) From
STATE WELL PERMIT#(if applicable) From To Ft.
DWQ or OTHER PERMIT#pf applicable) 227261 8.SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply G* From To Ft. - in. in.
DATE DRILLED 51119021 From To Ft. in. in.
TIME COMPLETED AM❑ PM CjZ From To Ft. in. in.
3.WELL LOCATION: 9.SAND/GRAVEL PACK:
Depth Size Material
CITY: DEEP GAP COUNTY Wittap3lia- From _To Ft.
From To Ft.
OFF POWDERHORN ESTATES DR OFFPOWDERHO From To Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
❑Slope ❑Valley ❑Flat ❑Ridge ❑Other From To Formation Description
(check appropriate box)
May be in degrees, 0 59 CLAYIEfRaVl:dlt SLATE
LATITUDE 3 _ minutes,seconds or 89 185 GRANITE
LONGITUDE in a decimal format 1 185 CRIBACF
Latitude/longitude source: L*GPS ❑Topographic map 165 420 {enurF
(location of well must be shown on a USGS topo map and —420 d26 MnIn
attached to this form if not using GPS)
426 ""D 61R/1NITE
4.WELL OWNER 49D 48D� GREMIGE
OWNER'S NAME () TT"� nT�'_NU 80 SM nes NITS �'' 3
avH�t�rz—i�•ox �.�o -�rc/vvrrc—rc,
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STREET ADDRESS jInI S11HRIgg LN g
IR �.
r - State FL Zip e CetIQY
O d00 ran 1 i5111
Are ode- ne1
number I„D;CR i C �•'ss``
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: F%40 ���$�_ 30 r 20_42LS
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO it 420_
c. WATER LEVEL Below Top of Casing: 40 - 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
RECORD HAS BEEN PR VIDED T WELL OWNER.
d. TOP OF CASING IS 1 , FT.Above Land Surface* I _ 1
*Top of casing terminated at/or below land surface may require 1
a variance in accordance with 15A NCAC 2C.0118 TIG"INATURE OF CeRTIFIED WELL CONT R DATE
e. YIELD(gpm): 40 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.E Rev.7/05

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