GW1-2022-09642_Well Construction - GW1_20221021

r RESIDENTLML WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 2780 220024
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 70
KEITH PRESNELL
g. WATER ZONES(depth):
.Well Contractor(Individual)Name From 240 To 245 From 330 To 331
DEWEY WRIGHT WELL&PUMP CO., INC From To From To
Well Contractor Company Name From To From To
STREET ADDRESS PO BOX 308 7. CASING: Thickness/
BOONE NC 28607 Depth Diameter Weight Material
From_Q_To_ Q_Ft. C, 118 3,9Q_ PVC
City or Town State Zip Code From To Ft.
8( 28 )-264-2651 From To Ft.
Area code- Phone number
2.WELL INFORMATION: 8. GROUT: Depth Material Method
SITE WELL ID#(ifapplicable) From 0 To 20 Ft. BENTONIT GRAVITY
— - -- -- _ ----From- To- - -'Ft-24-BAGS- — --
WELL CONSTRUCTION PERMIT#363914 From To Ft.
OTHER ASSOCIATED PERMIT#(if applicable)
9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply X From To Ft. in. in.
DATE DRILLED 09/22/2022 From To Ft. in, in.
TIME COMPLETED 03:00 AMU PM OX From To Ft. in. in.
4.WELL LOCATION: 10.SAND/GRAVEL PACK:
CITY: WEST JEFFERSON COUNTY ASHE Depth Size Material
From To Ft.
OFF WATERTANK RD OFF 221 OFF 421 From To Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) From To Ft.
TOPOGRAPHIC/LAND SETTING:
X Slope 0 Valley 0 Flat 0 Ridge 0 Other
(check appropriate box) 11.DRILLING LOG
May be in degrees, From TO Formation Description
LATITUDE — — 36.33713N minutes,seconds or 0 70 DIRT
LONGITUDE 81.47556W in a decimal format 70 180 GRANITE
— — 180 240 SHALE
Latitude/longitude source: X GPS 0 Topographic map 240 245 QUARTZ
(location of well must be shown on a USGS topo map and 245 330 GRANITE ,,,,,'' ��
attached to this form if not using GPS) 330 331 VOID
5.WELL OWNER 331 405 GRANITE GIC_ 172022
OWNER'S NAME NICOLETTE SEVERT
STREET ADDRESS 2769 WATERTANK RD -f ;AM R-Nf� U
WEST JEFFERSO NC 28694 Y
City or Town State Zip Code
(336 )- 977-6679
Area code- Phone number 12. REMARKS:
5GPM 240-245 15GPM 330-331
6.WELL DETAILS:
a. TOTAL DEPTH: 405
b. DOES WELL REPLACE EXISTING WELL? YES 0 NOX 1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C,WELL CONSTRUCTI STANDARDS,AND THAT A COPY OF THIS
(VnJI
c. WATER LEVEL Below Top of Casing: 60 FT. R R HAS BEEN PROV EDT T E WELL OWNER.
(Use"+"if Above Top of Casing) /
d. TOP OF CASING IS 1 FT.Above Land Surface` I �r
*Top of casing terminated attor below land surface may require SIGNATURE OF CERTIFIED WELL CONT AC R DATE
a variance in accordance with 15A NCAC 2C.0118. KEITH PRESNELL
e. YIELD(gpm): 20 METHOD OF TEST AIR PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn:Information Mgt., Form GWAa
1617 Mail Service Center-Raleigh,INC 27699-1617 Phone No.[phone] ext 568. Rev.3/07

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