GW1-2021-02399_Well Construction - GW1_20210722

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RESIDENTIAL WELL CONSTRUCTION RECORD
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North Carolina Department of Environment and Natural Resources-Division of Water Quality
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` WELL CONTRACTOR CERTIFICATION# 2780 200222-
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 95
KEITH PRESNELL g. WATER ZONES(depth):
Well Contractor(Individual Name) FrgIty OLE_To From To
DEWEY WRIGHT WELL&PUMP CO., INC. From To From To
Well Contractor Company Name From To From To
STREET ADDRESS p O BOX 309 6.CASING: Thickness/
Depth Diameter Weight Material
BOONE NC 28607 From To S Ft.614S 3,Sn pyG
City or Town State Zip Code From To Ft.
(.=.—) From To Ft.
Area code- one number
7.GROUT: Depth Material Method
2.WELL INFORMATION: From-gin jo- -20 F-ty __ _ gW =_.
SITE WELL ID#(if applicable) From TO FtanmA W
STATE WELL PERMIT#(if applicable) From To Ft.
DWQ or OTHER PERMIT#(if applicable) a34679 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply] From To Ft. in. in.
DATE DRILLED 719/2021 From TO Ft. in. in.
TIME COMPLETED AM❑ PMO7 From To Ft.—in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
Depth Size Material
CITY:DRY HOLE COUNTY WdMM From _To F,t.
From To Ft.
OFF L EATCAID RD OFF H{JlY-194 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, -p-as DIRT
LATITUDE 3 — M&I 530 minutes,seconds or as 48 —BLUE GRANITE
LONGITUDE — �rnbli in a decimal format e-33.o031— 48 %
_ 19LU€f6RhY GRANITE
Latitude/longitude source: k1 GPS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4.WELL OWNER
OWNER'S NAMEADAM MCIT E v
STREET ADDRES6/re
State Zip 7rD�B-�5t�
t itZ1t
( �
A eY a cfode- hone number
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 0 r_ ,
b. DOES WELL REPLACE EXISTING WELL? YES❑ NV
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 0 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDEDHE WELL OWNER.
d. TOP OF CASING IS FT.Above Land Surface* /
*Top of casing terminated-air below land surface may require ^(
a variance in accordance with 15A NCAC 2C.0118 'SIGNATURE OF C71FIRTIFIED ONT R DATE
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e. YIELD(gpm): 0 METHOD OF TEST i
PRIN A CONSTRUCTING THE WELL
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Submit the original to the Division of Water Quality within 30 days.Attn:Information Mgt., i
Form GW-1 a
1617 Mail Service Center-Raleigh,INC 27699-1617 Phone No.[phone] ext 568.I i Rev.7/05
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