GW1-2022-08622_Well Construction - GW1_20220419

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,; RESIDENTIAL WELL CONSTRUCTION RECORD
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0 k* 4;., j` North Carolina Department of Environment and Natural Resources-Division of Water Quality
^ ` 2780 i 210248
,•---- WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: i HTH
KEITH PRESNELL f. DISINFECTION:Type Amount 49
g. WATER ZONES(depth):
Well Contractor(Individual Name) From 195 To 202 From 291 To 292
OEWEY WRIGHT WELL &PUMP CO., INC.
From To From To
Well Contractor Company Name P.O.BOX 308 From To i From To ,
STREET ADDRESS 6.CASING: Thickness/
BOONS NC 28607
From 0 To Depth 85 Ft. 6 DiameterU8 Wei350ht PVC
Material
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 BENTONIT Gravity Flow
_SITE WELL ID#(if applicable) From To Ft.20 BAGS
STATE WELL PERMIT#(if applicable) From To Ft.
DWQ or OTHER PERMIT#(if applicable) 3391110 8.SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply u From To Ft. in. in.
3/30/2022
DATE DRILLED yy�� From To Ft. in. in.
TIME COMPLETED 03:00 AM❑ PM C] From To Ft. in. in.
9.SAND/GRAVEL PACK:
3.WELL LOCATION:
WARRENSVILLE SVIT T R AS Depth Size Material
CITY: COUNTY From_ _To Ft.
LOT 1 CHEROKEE OAKS OFF CHEROKEE OAKS LN 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 DIRT
_ N36.2'7.634 May be in degrees, 40 78 SOFT SHALE
LATITUDE 3 minutes,seconds of
LONGITUDE W81.31.527 in a decimal format 78 195 GRANITE
Latitude/longitude source: L GPS ❑Topographic map 195 202 QUARTZw-
(location of well must be shown on a USGS topo map and 202 291 GRANITE
attached to this form if not using GPS) 291 292 VOID
4.WELL OWNER 242 305 REC'-•�,6f31
OWNER'S NAMEAM WHITEHOUSE E V�
t5 .
STREET ADDRESS°PROTEC, 147 FINN HOLLOW LN
ADVANCE NC 27006 APR 19 2022
City or Town State Zip Code
( (336) 1- 813-2191 DQ ocoom BO ing Unit
Area code-Phone number
SWELL DETAILS: 3 11.
05 GPM 195-202 - '35 GPM 291 -292
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO1
1
60
c. WATER LEVEL Below Top of Casing: 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 PR IDE TO TH ELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land Surface* )*Top of casing terminated at/or below land surface may require . f5 a variance in accordance with 15A NCAC 2C.0118 E OF CERTI DWEL • 4/4
R DATE
40
e. YIELD(gpm): METHOD OF TEST Au 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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