GW1--03129_Well Construction - GW1_20230505

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.r I ., RESIDENTIAL WELL CONSTRUCTION RECORD
` . .tr N. North Carolina Department of Environment and Natural Resources-Division of Water Quality
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:":`ry 2780 220085 •
'`_ WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 63
KEITH PRESNELL g. WATER ZONES(depth):
Well Contractor(Individual)Name From 360 To 363
From 220 To 223 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/
Depth Diameter Weight Material
BOONE NC 28607 From 0 To 170 Ft. 6 1/A 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
SITE WELL ID#(if applicable) From 0 To 20 Ft. BENTONIT -- GRAVITY ---
From To Ft. 18 BAGS
WELL CONSTRUCTION PERMIT#362243 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 4/14/2023 From To Ft. in. in.
TIME COMPLETED 03:00 AM II PM OX From To Ft. in. in.
4.WELL LOCATION: 10.SAND/GRAVEL PACK:
CITY: BANNER ELK COUNTY WATAUGA Depth Size Material
From To Ft.
LOT#5 OFF FALCON VIEW OFF PIEGON ROOST( 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 _ _ 36.18415N minutes,seconds or 0 155 DIRT
LONGITUDE St.ato27W in a decimal format 155 220 223
20 GRANITF
_ _ GRANITE SHALE
Latitude/longitude source: X GPS 0 Topographic map 223 360 GRANITE
(location of well must be shown on a USGS topo map and 360 363 GRANITE .
-
attached to this form if not using GPS) 363 400 GRANITE I ';,: ;a --.
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5.WELL OWNER
OWNER'S NAME ANTHONY PALAZZO MAY U 2023
STREET ADDRESS PO BOX 3244
BOONE NC 28607 i ""`'"`"'
City or Town State Zip Code
(828 )- 260-6742
Area code- Phone number 12. REMARKS:
3 GPM 220-223
6.WELL DETAILS: 7 GPM 360 363
a. TOTAL DEPTH: 400
b. DOES WELL REPLACE EXISTING WELL? YES 0 NOX I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
c. WATER LEVEL Below Top of Casing: 100 FT. RECO HAS BEEN PRO IDEDT E WELL OWNER.
(Use"+"if Above Top of Casing) UU(( ��77 '
d. TOP OF CASING IS 1 FT.Above Land Surface* t/L L 7
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*Top of casing terminated at/or below land surface may require SIGNATURE OF CE IED WgL C 1 A DATE
a variance in accordance with 15A NCAC 2C.0118. KEITH PRESNELL
e. YIELD(gpm): 10 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 GW-la
1617 Mail Service Center—Raleigh,NC 27699-1617 Phone No.[phone] ext 568. ' ' Rev.3/07

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