GW1--03466_Well Construction - GW1_20230518

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`` 1 ''1,- '' RESIDENTIAL WELL CONSTRUCTION RECORD
..� It o 1 North Carolina Department of Environment and Natural Resources-Division of Water Quality
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' " ' WELL CONTRACTOR CERTIFICATION# 2780 230059
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 54
KEITH PRESNELL g. WATER ZONES(depth):
Well Contractor(Individual)Name From 140 To 160
From 260 To 265
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 60 Ft. 6 1/8 350 PVC
City or Town State Zip Code From To Ft.
(828 )-264-2651 From To Ft.
Area code- Phone number
2.WELL INFORMATION: 8. GROUT: Depth Material Method
-- --- - -SITE WELL ID#(if applicable) — From 0 To 20 Ft. BENTONIT GRAVITY
From To Ft. 24 BAGS
WELL CONSTRUCTION PERMIT#390162 From To Ft.
OTHER ASSOCIATED PERMIT#(if applicable)
9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply IX From To Ft. in. in.
DATE DRILLED 5/8/2023 . From To Ft. in. in.
TIME COMPLETED 03:00 AM 0 PM DX From To Ft. in. in.
4.WELL LOCATION:• 10.SAND/GRAVEL PACK:
CITY: TODD COUNTY ASHE Depth Size Material
From To Ft.
OFF GRANT HOUCK OFF 194S OFF HWY 221 HW1 From To Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) From To Ft. _
TOPOGRAPHIC/LAND SETTING:
0 Slope 0 Valley X Flat 0 Ridge 0 Other 11. DRILLING LOG •
(check appropriate box)
May be in degrees, From To Formation Description
LATITUDE _ _ 36.3383308 minutes,seconds or 0 50 DIRT
LONGITUDE 81.5388801 in a decimal format 50 140 GRANITE
— — 140 160 QUARTZ
Latitude/longitude source: X GPS 0 Topographic map 160 220 GRANITE
(location of well must be shown on a USGS topo map and 220 260 SHALE _t-
attached to this form if not usingGPS) 260 265 VOID �_,S'-.-1 L. a i •:S
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265 305 GRANITE E 0'--�,.,a'�.,..� �
5.WELL OWNER
OWNER'S NAME JEFF GRUBB MAY 1 $ 7023
STREET ADDRESS 939 NC HWY 194S
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TODD NC 28684. �; ;% "N.r:3
City or Town State Zip Code
(336 )- 977-0250
Area code- Phone number 12. REMARKS:
5 GPM 140-160
6.WELL DETAILS: 25 GPM 260-265
a. TOTAL DEPTH: 305
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 TANDARDS,AND THAT A COPY OF THIS
c. WATER LEVEL Below Top of Casing: 40 FT. REHAS BEEN PROVIDED TO WELL OWNER. ��
(Use"+"if Above Top of Casing) �X-LiZ �/L v ✓l Lr02 G d. TOP OF CASING IS 1 FT.Above Land Surface*
*Top of casing terminated at/or below land surface may require SIGNATURE OF CERTI IED WELL CONTRA R DATE
a variance in accordance with 15A NCAC 2C.0118. KEITH PRESNELL
e. YIELD(gpm): 30 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-1 a
1617 Mail Service Center—Raleigh,NC 27699-1617 Phone No.[phone] ext 568. Rev.3/07

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