GW1-2022-07083_Well Construction - GW1_20220801

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RESIDENTIAL WELL CONSTRUCTION RECORD
_ �C North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 2780 k 220116
1.WELL CONTRACTOR:
f. DISINFECTION:Type HTH Amount 19.0
KEITH PRESNELL g. WATER ZONES(depth):
Well Contractor(Individual Name) From 310 To 312 From 630 TO533
DEVVEY WVRiGHT 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 NC 28607 Depth Diameter Weight Material
From Tom_ Ft. 6 1IR 350 'aV('
City or Town State Zip Code From To Ft.
( 828 )254-2651 From To Ft.
Area code-Phone number 7.GROUT: Depth j
From 0 To Material Method
2.WELL INFORMATION: _
- _ - _.--- -- FtBENTONTT- _ Grasrity Flow
SITE WELL ID#(if applicable) From To Ft.19 BAGS
STATE WELL PERMIT#(f applicable) From To Ft.
DWQ or OTHER PERMIT#(d applicable) 246W &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply$] From To Ft. in. in.
DATE DRILLED 7/18/2022 From To Ft. in. in.
TIME COMPLETED 03:00 AM❑ PMX1 From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
Depth SizeR E C E, ri E Q
CITY:��� COUNTY ASHE From To Ft.
LOT 58 HIDDEN WN/AUTUMN LEAF WAY/E HIDD From _To Ft.
From TO Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code)
1+"t('c.'tn ProcowOno Unbt
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG DW
Q Slope ❑Valley ❑Flat ❑Ridge ❑Other From To Formation Description
(check appropriate box) 0 68 DIRT
May be in degrees,
LATITUDE 3 36,5251SN minutes,seconds or 68 173 GRANITE
LONGITUDE 81.37245W in a decimal format 173 196 SHALE
Latitude/longitude source: W GPS ❑Topographic map 196 310 GRANITE
(location of well must be shown on a USGS topo map and 310 312 QUARTZ
attached to this form if not using GPS) 312 380 SHALE
4.WELL OWNER 380 530 GRANITE
OWNER'S NAMEt7F"1:ER OKRKPKY 5W 582 SHALE
STREET ADDRESS716 BLUFF CT_ - 582 630 GRANITE
RAI.EIGH NC 28615 630 533 QUARTZ
City or Town State Zip Code , 700 GRANITE
C9( 1M )-274-4002
Area code-Phone number
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 700 2 C3,M4 310- 312 1 GMd 610-6l1
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOA]
c. WATER LEVEL Below Top of Casing: I W 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 PROVIDED T HE WELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land Surface`
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C.0118 SIGNATURE OF CERTIFIED WELL CONTRA R DATE
e. YIELD(gpm): 3 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-1 a
1617 Mail Service Center-Raleigh,NC 27699-1617 Phone No.[phone] ext 568. Rev.7/05
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