GW1-2022-06588_Well Construction - GW1_20220708

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RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
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WELL CONTRACTOR CERTIFICATION# 2780 21025I
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 73
KEITH PRESNELL
g. WATER ZONES(depth):
Well Contractor. W(Individual Name From 270 TO 275 From To
DEWEY VVRIGHT WELL &PUMP CO., INC.
From To From To
Well Contractor Company Name From To From To
STREET ADDRESS P.0.BOX 308 6.CASING: Thickness/
BOONE NC 28607 Depth Diameter Weight Material
From 0 To 28 Ft. 61/8 .350 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
-- —-- -------FTom 0 TO 20 Ft.=BENT011IT _ CrTSV�FlOy7
SITE WELL ID#(if applicable) From To Ft.
19 BAGS
STATE WELL PERMIT#(f applicable) From To Ft.SELFCERT
DWQ or OTHER PERMIT#(if applicable) 36MO &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply( From To Ft. in. in.
DATE DRILLED 6/14/2022 From To Ft. in. in.
TIME COMPLETED 03:00 AM❑ PM From To Ft. in. in.
9.SAND/GRAVEL PACK:
3.WELL LOCATION:
Depth Size Material
CITY: ZIONV=
COUNTY W== From To Ft.
OFF SMVERSTONE FARMS RD OFF SMVMZSTONE From -To Ft.
From TO Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) "� f�, ; V
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG JUL 0 S 2022
❑Slope ❑Valley ❑Flat ❑Ridge ❑Other From To Formation Description
(check appropriate box) 0 18 DIRT (nfor'nec.;.0 �r •3v;,or.
May be in degrees, t,t� t
LATITUDE 3 minutes,seconds or 1$ 196 GRANITE a ,Q[;
LONGITUDE in a decimal format 196 210 GRANITE/QUATRZ
Latitude/longitude source: I GPS ❑Topographic map 210 270 GRANITE
(location of well must be shown on a USGS topo map and 270 275 QUARTZ
attached to this form if not using GPS) 275 342 i GRANITE
4.WELL OWNER 342 360 SHALE
OWNER'S NAMEDAVID&A1W= MOUTOUX 360 425 GRANITE
STREET ADDRESS/Q PERRY BUILT HOMES, 135 SUN HAVEN
BOONE NC 28607
City or Town State Zip Code
( (828') _ 263-2028
Area code-Phone number
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 425 2 GPM 270-275
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOX)
c. WATER LEVEL Below Top of Casing: 60 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 PROVID %TO'THE WELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land Surface'
Top of casing terminated at/or below land surface may require 001 ~(a
a variance in accordance with 15A NCAC 2C.0118 SIGNAT E OF CERTIFIED L OR DATE
e. YIELD(gpm): 2 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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