GW1-2021-03217_Well Construction - GW1_20210625

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RESIDENTIAL WELL CONSTRUCTION RECOI RD
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North Carolina Department of Environment and Natural Resources-Division of Water Quality
2780 j 20027A
WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: HTH
KEITH PRESNELL f. DISINFECTION:Type Amount 74
g. WATER ZONES(depth):
Well Contractor(Individual Name) From 400 To 402 From To
DEVV-EY Vv IGHT WELL&PUMP CO., INC.
From To From To
Well Contractor Company Name From To From To
STREET ADDRESS P O.BOX 308 6.CASING: Thickness/
BOONE NC 2$607 Depth Diameter Weight Material
From 0 To 116 Ft. 6114 .188 GALV
City or Town State Zip Code From To Ft.
264-2651 From To Ft.
Area code-Phone number
2.WELL INFORMATION: 7.GROUT: Depth Material Method
From 0 To 20 Ft. BENTONIT Gravity Flow
SITEWELL ID#(if applicable) From To Ft:
STATE WELL PERMIT#('�f applicable) From To Ft.
DWQ or OTHER PERMIT#(f applicable) . 10715 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply From To Ft. in. in.
DATE DRILLED 6/11/2021 From To Ft. in. in.
TIME COMPLETED 03:00 AM❑ PM 21 From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
Depth Size Material
CITY: L NVI= COUNTY AVMY From To Ft.
OFF HIGHLAND MIST OFF GOLF COURSE RD OFF C From _To Ft.
From To Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
❑Slope ❑Valley ❑Flat ❑Ridge ❑Other From To Formation Description
(check appropriate box) 0 105, DIRT
May be in degrees,
LATITUDE 3 _ minutes,seconds or 105 - 116 GRAY GRANITE .
LONGITUDE _ _ in a decimal format 116 400 BLUE&GRAY GRANII
Latitude/longitude source: OXGPS ❑Topographic map 400 402 BIG CREMCE
(location of well must be shown on a USGS topo map and 402 425 BLUE GRANITE
attached to this form if not using GPS)
4.WELL OWNER
OWNER'S NAME CHARLES TEAL
STREET ADDRESS,%BOONE CONSTRUCTION, 189 CALLOW
BOOIJE NC 28607
City or Town State Zip Code J UN 2 5 2021
(_(� 773-1685 6
Area code-Phone number 111tormation Processing Unit
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 425 30 GPM 400-4M
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO KI
c. WATER LEVEL Below Top of Casing: 50 FT I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
(Use"+"if Above Top of Casing) 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED E WELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land Surface* use/\ / ?4 (� /
*Top of casing terminated at/or below land surface may require p W
a variance in accordance with 15A NCAC 2C.0118 SIGNATURE OF C rrrIFIFn WELL CONTR CTOR DATE
e. YIELD(gpm): 30 METHOD OF TEST Air KEITH PRESNELL
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
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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.7/05

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