GW1--04461_Well Construction - GW1_20230710

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RESIDENTIAL WELL CONSTRUCTION RECORD
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'£i,' North Carolina Department of Environment and Natural Resources-Division of Water Quality
- _...' WELL CONTRACTOR CERTIFICATION# 2780 230009
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 53
KEITH PRESNELL
g. WATER ZONES(depth):
Well Contractor(Individual)Name From 200 To 210 From 272 To 273
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 O To an Ft. A 1/A 350 P\fC
City or Town State Zip Code From To Ft.
(828 )-264-2651 From To Ft.
Area code- Phone number
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2.WELL INFORMATION: 8. GROUT: Depth Material Method
_ _ From 0 To 20 Ft..BENTONIT GRAVITY _
- SITE WELL-ID#(ifapplicable) - From To Ft. 18 BAGS
WELL CONSTRUCTION PERMIT#369755 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 6/27/2023 From To Ft. in. in.
TIME COMPLETED 03:00 AM 0 PM UX From To _ Ft. in. in.
4.WELL LOCATION: 10.SAND/GRAVEL PACK:
CITY: BANNER ELK COUNTY WATAUGA Depth Size Material
From To Ft.
LOT#18 OFF GREAT SKY DR OFF SHAWNEE OFF From To Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) From To Ft.
TOPOGRAPHIC/LAND SETTING:
0 Slope II Valley X Flat 0 Ridge 0 Other
(check appropriate box) 11. DRILLING LOG
May be in degrees, From To Formation Description
LATITUDE — 36.18783N minutes,seconds or 0 70 DIRT
LONGITUDE 81.83796W in a decimal format 70 190 GRANITF
— — 190 200 SHALE
Latitude/longitude source: X GPS 0 Topographic map 200 210 . GREEN GRANITE
(location of well must be shown on a USGS topo map and 210 272 GRANITE i.•_
attached to this form if not using GPS) 272 273 VOID /':=•• ? `~,/,.^-°I
5.WELL OWNER 273 305 GRANITE ' :.,,.L ' 3---- ti "'
OWNER'S NAME MITCH GOLDBERG C/O FARRELL SF- JUL1 Q 2023
STREET ADDRESS 471 LONNIE HENSON RD
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- V!LAS NC 28692 Ir.����,:� ; ,-,
City or Town State Zip Code
(828 )- 963-0277
Area code- Phone number 12. REMARKS: •
2 GPM 200-210
6.WELL DETAILS: 18 GPM 272-273
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 CONSTRUCT' .TANDARDS,AND THAT A COPY OF THIS
C. WATER LEVEL Below Top of Casing: 50 FT. RE R HAS BE OVIDED; WELL OWNER.
(Use"+"if Above Top of Casing)
d. TOP OF CASING IS 1 FT.Above Land Surface* j 3O
*Top of casing terminated at/or below land surface may require IGNATURE F CERTIF ED WEL CONTRAC R DATE
a variance in accordance with 15A NCAC 2C.0118. KEITH PRESNELL ,
e. YIELD(gpm): 20 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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