GW1-2022-02832_Well Construction - GW1_20220224

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RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 2780 220011
1.WELL CONTRACTOR:
f. DISINFECTION:Type HTH Amount 70
KEITH PRESNELL g. WATER ZONES(depth):
Well Contractor(Individual Name) From 105 To 110 From To
DEWEY VVKltaH T 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/
BOONE NCgj Depth Diameter Weight Material
From 0 To 30 Ft. 6I1$ s50 PVC
City or Town State Zip Code From To Ft.
( 828 )-264-2651 From To Ft.
Area code-Phone number
2.WELL INFORMATION: 7.GROUT: Depth Material Method
-- ----- -- — — From 0 TO 20 F_t.RFNTC)NT C7riwitVTnnw
SITE WELL ID#(if applicable) From—TO—+ Ftj4RACTC
STATE WELL PERMIT#(if applicable) From To Ft.
DWO or OTHER PERMIT#(Ff applicable) 166629 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply From To Ft. in. in.
DATE DRILLED I/27/2022 From To Ft. in. in.
TIME COMPLETED 03:00 AM❑ PM K11 From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
Depth Size Material
CITY-. BLOWING ROCK COUNTY WATAUGA From To Ft.
OLD ORCHARD RD OFF VALLEY VIEW OFF WOND From _To Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) From To 'Ft.
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
❑Slope ❑Valley ❑Flat ❑Ridge ❑Other From TO Formation Description
(check appropriate box) 0 18 DIRT
May be in degrees,
LATITUDE 3 36.12488N minutes,seconds or is ins GRANITE
LONGITUDE 91-69W W in a decimal format 105 i 10 011ART7
Latitude/longitude source: W GPS ❑Topographic map i in Wn rftANIIE
(location of well must be shown on a USGS topo map and 2M 222 cSHAI F
attached to this form if not using GPS) 70 Rdn GRANITE
4.WELL OWNER 340 350 SHALE
OWNER'S NAME$IC'AARTi T'R OR 35n 425 GRALI'Tr-
STREET ADDRESSa/a PARADIGM CUSTOM HOME BUILDERS_ 15 - - - ngn/m n
800NE NC 28607 — t 24 �?
'-
City or Town State Zip Code
B
cc )-964-0048
Area code-Phone number DIM V1al
5.WELL DETAILS: 11.REMARKS: ' ►< mw l.�i�'T
a. TOTAL DEPTH: 425 1 GPM 105- 110
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO)1(]
C. WATER LEVEL Below Top of Casing: 80 FT. I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
(Use"+"if Above Top of Casing) 15A NCAC 2C,WELL CONSTRU94qN STANDARDS,AND THAT A COPY OF THIS
RE R HAS BEE P VIDE O HE WELL OWNER.
d. TOP OF CASING IS 1 FT Above Land Surface" I
*Top of casing terminated at/or below land surface may require
U2 �_�z
a variance in accordance with 15A NCAC 2C.0118 SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): 1 METHOD OF TEST Air KEITH PRESNELL
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
I
Submit the original to the Division of Water Quality within 30 days.Attn: Information Mgt., Form GW-1 a
1617 Mail Service Center-Raleigh, NC 27699-1617 Phone No.[phone] ext 558. Rev.7/05

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