GW1-2022-08621_Well Construction - GW1_20220505

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1 - . ,. RESIDENTIAL WELL CONSTRUCTION RECORD
��!y)t: �co North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 2780 220021
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1.WELL CONTRACTOR:KEITH PRESNELL f. DISINFECTION:Type 1 HTH Amount 39
g. WATER ZONES(depth):
Well Contractor(Individual Name) From 165 To 169 From 182 To 183
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/
BOONE NC 28607 Depth Diameter Weight Material
From 0 To 40 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
From 0 To 20 Ft.BENTONIT Gravity Flow
SITE WELL ID#(if applicable) . From To Ft.22 BAGS
- STATE-WELL-PERMIT#ffapplicable) ------ - — - From— -- To-- ----- Ft. — _______._ -- -- -
DWQ or OTHER PERMIT#(if applicable) 367234 8.SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply 21 From To Ft. in. in. F.[ ,..
DATE DRILLED 4/25/2022 From To Ft. in. in.
TIME COMPLETED 03:00 AM❑ PM 6 From To Ft. in. in.
9.SAND/GRAVEL PACK:
3.WELL LOCATION:
WEST JEFFERSON A Depth Size Material
CITY: COUNTY From _To Ft.
578 SADDLE GAP RD OFF WEST BUFFALO OFF CEN 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 30 DIRT
May be in degrees,
LATITUDE 3 N36.25.357 minutes,seconds or 30 165 GRANITE
LONGITUDE WO$1.33.396 in a decimal format 165 169 QUARTZ
Latitude/longitude source: 2 GPS ❑Topographic map 169 182 GRANITE
(location of well must be shown on a USGS topo map and 182 183 -VOID
attached to this form if not using GPS) 183 205 GRANITE
4.WELL OWNER P 4 ,
OWNER'S NAMELMETTA SWAFFORD IVFDC_
STREET ADDRESS
$$SADDLE GAP RD, MAY O 5 202�_
- WEST JEFFERSON NC 28694
City or Town State Zip Code
( (813) ) 734-1882 IP,",„ `1 F OCE, 'r')G..IM
Area code-Phone number
5.WELL DETAILS: 11.REMARKS: •
a. TOTAL DEPTH: 205 2 GPM 165- 169 18 GPM 182- 183
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOXI
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 CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
RECORD HAS BEEN PROVID iiii HE WELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land Surface* ^
*Top of casing terminated at/or below land surface may require 5*" . n1Z
a variance in accordance with 15A NCAC 2C.0118 SIGN U E CER FIED WELL CONT ACTO DATE
e. YIELD(gpm): 20 METHOD OF TEST Air KEITH PRESNELL
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
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Submit the original to the Division of Water Quality within 30 days.Attn: Information Mgt., Form GW-la
1617 Mail Service Center-Raleigh, NC 27699-1617 Phone No. [phone] ext 568.1 Rev.7/05

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