GW1--04411_Well Construction - GW1_20230710

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_.
', t{n ,\ ' RESIDENTIAL WELL CONSTRUCTION RECORD
f Q; North Carolina Department of Environment and Natural Resources-Division of Water Quality
y Z ` ? WELL CONTRACTOR CERTIFICATION# 2780 2201110
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 22
KEITH PRESNELL g. WATER ZONES(depth):
Well Contractor(Individual)Name From 110 To 111 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/
BOONE NC 28607 Depth Diameter Weight Material
From 0 To 68 Ft. 6 1/8 350 P\/C.
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'#(ifapplicable)------ --
From From To Ft. 28 BAGS
WELL CONSTRUCTION PERMIT#224947 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 6/28/2023 From To' Ft. in. in.
TIME COMPLETED 03:00 AM 0 PM II)( From To Ft. in. in.
4.WELL LOCATION: 10.SAPID/GRAVEL PACK:
CITY: BANNER ELK COUNTY AVERY Depth Size Material
From To Ft.
OFF OLD FARM OFF GUALTNEY OFF HWY 194 OF 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 II Ridge 0 Other
(check appropriate box) 11.DRILLING LOG -
May be in degrees, From To Formation Description
LATITUDE — — 36.18310N minutes,seconds or 0 58 DIRT
LONGITUDE 81.84987W in a decimal format 58 110 GRANITE
— — - 110 111 VOID
Latitude/longitude source: X GPS o Topographic map 111 145 GRANITE
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
5.WELL OWNER ,
OWNER'S NAME STEPHEN HARTMAN
STREET ADDRESS 109 RONELE DR F 7: _;1 I�c�zs
BRANDON- - FL 33511
City or Town State Zip Code jut I 1 j 2023
(813 )-,310-0125 ,
Area code- Phone number 12. REMARKS: in;our.:a.fan ?f ' ' '• Unk
30 GPM 110-111 D:s;afr�'JG
6.WELL DETAILS:
a. TOTAL DEPTH: 145
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 CONSTRUC STANDARDS,AND THAT A COPY OF THIS
c. WATER LEVEL Below Top of Casing: 4Q FT. RECORD HAS BEEN PROVIDE mg E WELL OWNER. —��� ^
(Use"+"if Above Top of Casing) `JJ
d. TOP OF CASING IS 1 FT.Above Land Surface* r ' `_ � '/� l� I �v
*Top of casing terminated at/or below land surface may require SI,NATU' OF CERT IED WELL CONTRACTOR 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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