GW1-2022-01215_Well Construction - GW1_20220103

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RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
2780 210105
WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: f. DISINFECTION:Type 'HTH Amount 46
KEITH PRESNELL
g. WATER ZONES(depth):
Well Contractor(Individual Name) From 196 To 204 From 270 To 272
DEVVEY VVRIGHT iAELL &PUMP CO., INC.
From To From To
Well Contractor Company Name From TO From TO
STREET ADDRESS P.O.BOX 308 6.CASING: Thickness/
BOONS NC 28607 Depth Diameter Weight Material
From 0 To 121 Ft. (31I4 .188 CIALV
City or Town State Zip Code From To Ft.
( US )_ 454.2651 From To Ft.
Area code-Phone number 7.GROUT: Depth Material Method
2.WELL INFORMATION: From 0 To 24 Ft.BENTONIT GravltyFlaw
--—SITE-WEL-L-1D-#(if applicable) ------------From 32 BAGS-- From To------F;t._.-.
STATE WELL PERMIT#(if applicable) From To Ft.
763626
DWO or OTHER PERMIT#(if applicable) &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply From To Ft. in. in.
DATE DRILLED 1219/2021 From To Ft. in. in.
TIME COMPLETED AM❑ PM tJ From To Ft. in. in.
3.WELL LOCATION: 9.SAND/GRAVEL PACK:
BANNER EIX AVERY Depth e° Material
CITY: COUNTY From To Ft. n
LOT 31 OFF SILVER FOX LN OFF SILVER.SPRINGS From _To Ft.
From _To Ft. ew,7!(9
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) SSrj,*
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG glow'
❑Slope ❑Valley ❑Flat ❑Ridge ❑Other From TO Formation Description
(check appropriate box) 0 111 DIRT
36.166664 Maybe in degrees, 111 196 GRANITE
LATITUDE 3 minutes,seconds or
LONGITUDE _ - in a decimal format 196 204 QUARTZ
Latitude/longitude source: IN GPS ❑Topographic map 204 270 GRANITE
(location of well must be shown on a USGS topo map and 270 272- VOID
attached to this form if not using GPS) 272 305 GRANITE
4.WELL OWNER
OWNER'S NAME BANNERMANOR CORD
,STREET ADDRES o CONSTRUCTION_, BUCK_
CPIE
RaANMa
City or Town State Zip Code
(( ) 387-7310
Area code-Phone number
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 305 5 GPM 196-M4 25 GPM 270-272
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO)IL
C. WATER LEVEL Below Top of Casing: $0 FT. I DO HEREBY CERTIFY THAT THIS WELLWAS 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 PROV EDT 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 CERTIFIE17 WELL CONTRACTOR DATE
34 Air e. YIELD(gpm): METHOD OF TEST KEITH PRESNELL
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
kn
Submit the original to the Division of Water Quality within 30 days.Attn: Information MOt., Form GW-1 a
1617 Mail Service Center-Raleigh,NC 27699-1617 Phone No.[phone] ext 568. Rev.7/05

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