GW1-2021-02344_Well Construction - GW1_20210722

� ff.: RESIDENTIAL WELL CONSTRUCTION RECORD
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North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 2780 I' 200184
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1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount
KEITH PRESNELL g. WATER ZONES(depth):
Well Contractor(Individual Name)
From gar► To From 270 To
DEO EY WRIGHT.VVELL&PUMP CO., INC. From 320 To From 60 To
Well Contractor Company Name From_To From��To
STREET ADDRESS R n TtOX-408 6.CASING: Thickness/
Depth Diameter Weight Material
BOONE NC 28607 From 0 To�� ' G Ft. .V
City or Town State Zip Code - — `����
From To Ft.
From To Ft.
Area code-PhonWlumber
7.GROUT: Depth Material Method
2.WELL INFORMATION:
- -- - FromT0 To 20-- Ft 'j' GrapjW MIOW
SITE WELL ID#(if applicable) From—To—_ Ftj S RAGS,
STATE WELL PERMIT#of applicable) From To Ft.
DWQ or OTHER PERMIT#(if applicable) 14092St._ &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply*] From To Ft. in. in.
DATE DRILLED .. _71212021 From To Ft. in. in.
TIME COMPLETED AM❑ .PN)p From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
Depth Size Material
CITY:C_RESTON COUNTY ASTaTti . From _To Ft.
From To Ft.
20?94 HWY 8W OFF HWY W67 OFF HWY 421 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 � minutes,seconds or
LONGITUDE iirno�+c�Inc in a decimal format
so go eREMeE
Latitude/longitude source: il GPS ❑Topographic map
(location of well must be shown on a USGS topo map and
270 270—
attached to this form if not using GPS) eREMeE
N c
4.WELL OWNER N .q
a am GREMICE
OWNER'S NAM EKIE PFJCsa GRANITE
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STREET ADDRES§0794 HW 881F am m GRE ICE Tj u3
xn 400 GRANKE!
I y r wn State Zip — —�TC°° I -� j5 O
lltBhl)-30-1901
Area code-Phone number
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5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: MA O.M GPM 90 0z5 GM-li-
b. DOES WELL REPLACE EXISTING WELL? YES❑ Nt-❑ (n nc n_ 70;n.27GPM men
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 Casing 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO ELL OWNER.
d. TOP OF CASING IS FT.Above Land Surface* 4- 1
*Top of casing terminated a or below land surface may require
a variance in accordance with 15A NCAC 2C.0118 SIG A RE OF TIFIED WELL COI
TRA DATE
e. YIELD(gpm): i METHOD OF TEST Air
PRINTED NAME OF PERS CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days.Attn:Information Mgt.,
i 1617 Mail Service Center-Raleigh, INCorm GW-1a
C 27699-1617 Phone No.[phone] ext 568. I Rev.7/05
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