GW1-2021-02709_Well Construction - GW1_20210901

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RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
.� �. 200234
n„ WELL CONTRACTOR CERTIFICATION# 80
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1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 121
KEITH PRESNELL
g. WATER ZONES(depth):
Well Contractor((Individual Name)) From 42 To 43 From 597 ToS99
DEWEY WRIGHT WELL&PUMP CO., INC.
From To ' From To
Well Contractor Company Name From To From To
STREET ADDRESS A O.BOX 30$ 6.CASING: Thickness/
BOONE NC 28607 Depth Diameter Weight Material
From 0 To 35 Ft. 61/8 .350 PVC
City or Town State Zp Ckde� From To Ft.
( 82$ )-264-2651 1 "s� From To Ft.
Area code-Phone number
2.WELL INFORMATION: 7.GROUT: Depth Material Method
_ tiEP X 1 2021 From 0 To 20 Ft.BFNrONIT GTayiwFlow
SITE WELL ID#(if applicable) 1 iryt From To Ft.16BAGS
STATE WELL PERMIT#(if applicable) IYi(lrl"�"` ]f From To Ft.
DWQ or OTHER PERMIT#(if applicable) i Vy� &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply From To Ft. in. in.
DATE DRILLED 8/19/2021 From To Ft. in. in.
TIME COMPLETED 03.00 AM❑ PM6 From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
BANNER ELK AVF�tY Depth Size Material
CITY: COUNTY From To Ft.
LOT 18 OFF TALON TRAIL OFF EAGLES NEST TRAI From _To Ft. -
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) 0 25 DIRT
May be in degrees,
LATITUDE 3 N36;11.861 minutes,seconds or 25 42 GRAY GRANITE
LONGITUDE W081+55.257 in a decimal format 42 43 CREVICE
Latitude/longitude source: ®GPS ❑Topographic map 43 597 BLUEfGRAY GRANITE
(location of well must be shown on a USGS topo map and 597 5N CREVICE
attached to this form if not using GPS) 59$ 645 BLUE GRANITE
4.WELL OWNER
OWNER'S NAMETONY BUDA
STREETADDRESsA31 N 248TH CIRCLE,
WATERL00 NE 68069
City or Town State Zip Code
L(8= -387-1418
Area code-Phone number
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 645 2 GPM 42-43 4 GPM 597-599
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO)U
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 CONS CTIDNS TANDARDS,AND THAT A COPY OF THIS
RECORD HAR)n /S YROV E TO THE WELL OWNER.
aJ 30
d. TOP OF CASING IS 1 FT.Above Land Surface* O
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C.0118 SIGNATURE OF CERTTFrED WELL CONMCTOR DATE
e. YIELD(gpm): 6• METHOD OF TEST Air KEITH PRESNELL
PRINTED NAME OF PERSON CONSTRUCTING 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 568. Rev.7/05

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