GW1--07903_Well Construction - GW1_20231205

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4' RESIDENTIAL WELL CONSTRUCTION RECORD
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3' f , ' North Carolina Department of Environment and Natural Resources Division of Water Quality
::::: •* WELL CONTRACTOR CERTIFICATION# 2780 2201I15
1.WELL CONTRACTOR: f. DISINFECTION:Type:HTH Amount 64
KEITH PRESNELL g. WATER ZONES(depth):
Well Contractor(Individual)Name From 260 To 265 From 380 To 386
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 f
BOONE NC 28607 From tl To 58 Ft. F 1/8 359 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__ __._Et 1.8_BAGS ____ __— ___ __ __ _
WELL CONSTRUCTION PERMIT# 183306 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 11/16/2023 From To Ft. in. in.
TIME COMPLETED 03:00 AM D PM DX From To Ft. in. in.
4.WELL LOCATION: 10.SAND/GRAVEL PACK:
CITY: BANNER ELK - COUNTY WATAUGA Depth Size Material
From To Ft.
OFF SPICE RIDGE RD OFF KELLERSVILLE RD OF From To Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) From To Ft.
TOPOGRAPHIC/LAND SETTING:
X Slope 0 Valley 0 Flat 0 Ridge 0 Other
(check appropriate box) 11. DRILLING LOG
Maybe in degrees, From To Formation Description
LATITUDE — — 36.23026 minutes,seconds or 0 40 DIRT
LONGITUDE 81.86053 in a decimal format 40 260 GRANITE
— — 260 265 GRANITE
Latitude/longitude source: X GPS 0 Topographic map 265 380 GRANITE
(location of well must be shown on a USGS topo map and 380 386 GRANITE
attached to this form if not using GPS) 386 405 • GRANITE
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5.WELL OWNER
OWNER'S NAME RON PABISZ .,,., ,�
STREET ADDRESS 9415 SUN POINTE DR IP-;�ram' ;0.,�„ \s Li
BOYNTON BEACI- FL 33437 — F rr 4 �► 'OnCity or Town State Zip Code D_L
( 954 )- 600-3183 ,�,-,r,�,^.:>'3 Ulat
Area code- Phone number int^�'rr'"'�`n
12. REMARKS: p`vv3 '
1 GPM 260-265
6:WELL DETAILS:"
2 GPM 380-386
a. TOTAL DEPTH: 405
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 STANDARDS,AND THAT A COPY OF THIS
c. WATER LEVEL Below Top of Casing: 100 FT. RECORD HAS BEEN P VIDEO O E WELL OWNER. '
(Use"+"if Above Top of Casing) °j�� e411 )/
d. TOP OF CASING IS 1 FT.Above Land Surface*
V/ /! —�7 a 3
*Top of casing terminated at/or below land surface may require SIGNATURE OF CERTIFIED WELL CONTRAC OR DATE
a variance in accordance with 15A NCAC 2C.0118. KEITH PRESNELL '
e. YIELD(gpm): 3 METHOD OF TEST AIR PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Inform Ition Mgt., Form GW-la
1617 Mail Service Center—Raleigh, NC 27699-1617 Phone No.[phone] ext 568.' ' Rev.3/07

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