GW1-2021-02798_Well Construction - GW1_20210811

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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# 90 i 210091
1.WELL CONTRACTOR: If. DISINFECTION:Type HTH Amount 105
KEITH PRESNELL
g. WATER ZONES(depth):
Well Contractor(Individual Name) From 105 To 106 From 440 To 442
DEWEY WRIGHT WELL &PUMP CO., INC.
From To From To
Well Contractor Company Name From - To From To
STREET ADDRESS P.O.BOX 308 6.CASING: Thickness/
BOOM NC 28607 Depth Diameter Weight Material
From 0 To 67 Ft. 61/8 .350 PVC
City or Town State Zip Code From To Ft.
( 828 )264-2651 From To Ft.
Area code-Phone number
7.GROUT: Depth Material Method
2.WELL INFORMATION: From 0 To 20 Ft.BENTO1= Grgw11yFlow
SITE WELL ID#(if applicable) From To Ft.
STATE WELL PERMIT#(if applicable) From To Ft.
DWO or OTHER PERMIT#(if applicable) 331284 - &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply From To Ft. in. in.
DATE DRILLED 7/28/2021 From To Ft. in. in.
TIME COMPLETED 03:00 AM❑ PM From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
Depth Size Material
CITY: GRES'rON COUNTY From _To Ft.
OFF u=.PMX RD OFF HWY 67/88 OFF HWY 421 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 40 CLAY
N36.399824 May in degrees, d0 50 SANDSTONE
LATITUDE 3 minutes,seconds or
LONGITUDE W-81.682672 in a decimal format 50 105 GRANITE
Latitude/longitude source: IOGPS ❑Topographic map 105 105 CREVICE ANI
GRANITE
(location of well must be shown on a USGS topo map and 105 280,
c�
attached to this form if not using GPS) 280 282 CREVICE
4.WELL OWNER 282 425 GRANITEjv
OWNER'S NAMEIMATH&CHELSAA ROOP. 425 440 QUARTZJGRANITE { 4a-
STREET ADDRES9435 W PFAX•RD 440 442 CREVICE r.�
CRMON NC 28615 442 520 GREEN GRANITE
City or Town State Zip Code
(3c 36) -W7-3478
Area code-Phone number
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 520< 0.25 GPM 105- 106 1.75 GPM 440-442
b. DOES WELL REPLACE EXISTING WELL? YES❑ - NOX)
c. WATER LEVEL Below Top of Casing: 20 FT. I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
(Use"+"if Above Top of Casing) 15A NCAC 2C,WELL CONSTRU STANDARDS,AND THAT A COPY OF THIS
RECORD HAS E O T E WELL OWNER.
d. TOP OF CASING IS 1• FT.Above Land Surface' l
Top of casing terminated at/or below land surface may require _
a variance in accordance with 15A NCAC 2C.0118 SIGNATURE OF CERTIFIED WELL CONTRAC DATE
e. YIELD(gpm): 2-- METHOD OF TEST Alf KEIPRINTED NAME OF EPERSON CONSTRUCTING THE WELL
I
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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