GW1--04268_Well Construction - GW1_20230626

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` 'R ESIDENTIAL.WELL CONSTRUCTION RECORD
a ?K 1. a North Carolina Department of Environment and Natural Resources-Division of Water Quality
" WELL CONTRACTOR CERTIFICATION# 2780 220079-1
1.WELL CONTRACTOR: f. -DISINFECTION:Type HTH Amount 136
KEITH PRESNELL
g. WATER ZONES(depth):
Well Contractor(Individual)Name
From 360 To 390 From To
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 40 Ft. 6 1/6 350 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 20 Ft. BENTONIT GRAVITY
SITE WELL ID#(if applicable) From To Ft;20 BAGS
WELL CONSTRUCTION PERMIT#373909 From To Ft.
OTHER ASSOCIATED PERMIT#(if applicable)
9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply CO( From To Ft. in. in.
DATE DRILLED 6/1/2023 From To Ft. in. in.
TIME COMPLETED 03:00 AM() PM O)( From To Ft. in. in.
4.WELL LOCATION: 10.SAND/GRAVEL PACK:
CITY: DRY HOLE COUNTY WATAUGA Depth Size Material
From To Ft.
232 PARK ST, OFF QUEEN ST, OFF STRAIGHT ST From To Ft. I t`"' E VE •�3"_'`'•
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) From To Ft. v a"'�r A" '"
TOPOGRAPHIC/LAND SETTING:• J U N 2, 6 2023
0 Slope 0 Valley X Flat II Ridge f Other 11. DRILLING LOG
(check appropriate box)
May be in degrees, From To FormatiRp tiptiotRr•::•::f. >,�'t Uri
LATITUDE — — 36.22996N minutes,seconds or 0 30 DIRT r 1Ak , 'limey
81.69069W in a decimal format 30 320 1 S�
LONGITUDE GRANITE
— — 320 360 SHALE
Latitude/longitude source: )1 GPS o Topographic map 360 390 QUARTZ
(location of well must be shown on a USGS topo map and 390 660 GRANITE
attached to this form if not using GPS) 660 690 SHALE
5.WELL OWNER 690 730 GRANITE
730 760 QUARTZ GRANITE MIX
OWNER'S NAME DINO HACKETT 760 1005 GRANITE
STREET ADDRESS 1152 KEARNS-HACKETT RD
PLEASANT GARD NC 27313
City or Town State Zip Code
(336 )_ 362-2041
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Area code- Phone number 12. REMARKS:
.5 GPM 360-390
6.WELL DETAILS:
a. TOTAL DEPTH: 1005
b. DOES WELL REPLACE EXISTING WELL? YES II NO)IC 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: 300 FT. RECORD HAS BEEN PROVIDE THE WELL OWNER.
(Use"+"if Above Top of Casing) (9 ( � J^2��
d. TOP OF CASING IS 1 . FT.Above Land Surface* ) 5
*Top of casing terminated at/or below land surface may require SIGNATURE OF CERTIFIED ELL O OR 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
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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