GW1-2023-01808_Well Construction - GW1_20230223

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.“- .1. RESIDENTIAL WELL CONSTRUCTION RECORD
e - ,g i North Carolina Department of Environment and Natural Resources-Division of Water Quality
.,au WELL CONTRACTOR CERTIFICATION# 2780 220149
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 46'
• KEITH PRESNELL g. WATER ZONES(depth):
Well Contractor(Individual)Name
From 140 To 142 From 190 To 193
DEWEY WRIGHT WELL&PUMP CO., INC From 280 To 285 From To
Well Contractor Company Name From To _ From_ To
STREET ADDRESS PO BOX 308 7. CASING: Thickness/
Depth Diameter Weight Material
BOONE NC 28607 From 0 To 41 Ft. A 1/R 350 PVC
City or Town State Zip Code From To Ft.
(828 )-264-2651 From To Ft.
Area code- Phone number
2.WELL INFORMATION: 8. GROUT: Depth Material Method
From 0 To.20Ft. BENTONIT GRAVITY
SITE WELL ID#(if applicable) From To Ft. 20 BAGS
WELL CONSTRUCTION PERMIT# 184204 From To Ft.
OTHER ASSOCIATED PERMIT#(if applicable)
9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply 0 From To Ft. in. in.
DATE DRILLED 2/1/2023 From To Ft. in. in.
TIME COMPLETED 0300 AM 0 PM OX From To Ft. in. in.
4.WELL LOCATION: 10.SAND/GRAVEL PACK:
CITY: SUGAR GROVE COUNTY WATAUGA Depth Size Material
From To 'Ft.
OFF KETERA RIDGE OFF MANTERA RIDGE OFF E From To Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) From To Ft.
TOPOGRAPHIC/LAND SETTING:
0 Slope 0 Valley 0 Flat 0 Ridge 0 Other 11. DRILLING LOG
(check appropriate box)
May be in degrees, From To Formation Description
LATITUDE _ — 36.13200 minutes,seconds or 0 29 DIRT
LONGITUDE 81.47648 in a decimal format 29 140 GRANITE
— — 140 142 PINK GRANITE
Latitude/longitude source: X GPS a Topographic map 142 190 GRANITE
(location of well must be shown on a USGS topo map and 190 193 PINK GRANITE
attached to this form if not using GPS) 193 280 GRANITE
5.WELL OWNER 280 285 GRANITE QUARTZ
285 305 GRANITE
OWNER'S NAME JIM &KATE KERWIN C/O TM WOOD(
STREET ADDRESS
PO BOX 584 r Y-y .I
BOONE NC 28607 TEB 2 ^ ZOZ3
City or Town State Zip Code - —
( 980 )- 616-2895 Int;_x :a;:::n i'm=:P=:: 7 t_In:i
12. REMARKS: ,-", :a' �-''-'
Area code- Phone number .
1 GPM 140-142
6.WELL DETAILS: 1 GPM 190 193
a. TOTAL DEPTH: 305 3 GPM 280 285
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C,WELL CONSTRUCTION NDARDS,AND THAT A COPY OF THIS
c. WATER LEVEL Below Top of Casing: 80 FT. R ORD HAS BEEN PROVIDED TO T E ELL OWNER.
(Use"+"if Above Top of Casing) •/1 I ^? -go
d. TOP OF CASING IS 1 FT.Above Land Surface*
*Top of casing terminated at/or below land surface may require SIGNATURE OF CE FIED WELL ONTRAC DATE
a variance in accordance with 15A NCAC 2C.0118. KEITH PRESNELL
e. YIELD(gpm): 5 METHOD OF TEST AIR PRINTED NAME OF PERSON CONSTRUCTING THE WELL
i
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.3/07

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