GW1-2021-02343_Well Construction - GW1_20210722 (2)

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RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 2780 ! 210046
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount g7
KEITH PRESNELL g• WATER ZONES(depth):
Well Contractor(Individual Name) From ovc To From can To
DEVVEY WRIGHT WELL&PUMP CO., INC. From To From�P To
Well Contractor Company Name From To From To
STREET ADDRESS A O.BOX 308 6.CASING: Thickness/
BOONE NC 22607 Depth Diameter Weight Material
8 [:AT 9
City or Town State Zip Code From 0 To 6; Ft. 6 114 18From To Ft.
( $78 )264-2fi51 From To Ft.
Area code-Phone number
7.GROUT: Depth Material Method
2.WELL INFORMATION:
-- - _. ._ _ _ From 0 To Ft r
SITE WELL ID#(If applicable) From To Ft.� �?gam
STATE WELL PERMIT#(if applicable) From To Ft.
DWQ or OTHER PERMIT#(if applicable) 115134 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply] From To Ft. in. in.
DATE DRILLED �t2mi From To Ft. in. in.
TIME COMPLETED AM❑ PM)p From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
Depth Size Material
CITY:CRESTON COUNTY ASHE From To Ft.
From To Ft.
OFF HAWKS VIEW TERRACE OFF STONEGATE LN 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,
LATITUDE 3 N3 minutes,seconds or
LONGITUDE iirnot♦�0 f"A in a decimal format
Latitude/longitude source: )GPS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS) cv r_
CREVICE, �
4.WELL OWNER GRANITE n u
OWNER'S NAM o��BE,,T " +,� Fri
STREET ADDRES� PKW, C err
o�
State Zip 1 9�
c
Area code- one number
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: SGO n 25 GPM 21H i 75 GPM wrn
b. DOES WELL REPLACE EXISTING WELL? YES❑ Ng(O �vxs ivr�4
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c. WATER LEVEL Below Top of Casing:� FT. I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
(Use"+"if Above Top of Casili" 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
REC RD HAS BEEN PRO IDED TO E WELL OWNER.
d. TOP OF CASING IS FT.Above Land Surface' Z'r i 'I " A
*Top of casing terminated a i below land surface may require 1
a variance in accordance with 15A NCAC 2C.0118 SIUNATURE OF CPW I A E D WELL ON DATE
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e. YIELD(gpm): 2 METHOD OF TEST Pdr PRIN A iICONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days.Attn:Information Mgt., Form GW-1a
1617 Mail Service Center-Raleigh,NC 27699-1617 Phone No.[phone] ext 56d Rev.7/05
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