GW1-2021-05469_Well Construction - GW1_20210722

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RECENED
RESIDENTIAL WELL CONSTRUCTION RECORD
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North Carolina Department of Environment and Natural Resources-Division of Water Quality J U L 2021
WELL CONTRACTOR CERTIFICATION# Information Processing UnitW , n
1.WELL CONTRACTOR: f. DISINFECTION:Type 114T�—Amount—109
KEITH PRESNELL g. WATER ZONES(depth):
Well Contractor(Individual Name) From 6g Tom=_ From 40S Toque
UEVVF-Y'M1GH T WELL &PUMP CO., INC:. From To From To
Well Contractor Company Name From To From To
STREET ADDRESS P n 11ox-408 6.CASING. Thickness/
Depth Diameter Weight Material
BOONE NC 2MM From_To—HS-- Ft. _ 0 We
City or Town State Zip Code From To Ft.
( =_)mLwn. From To Ft.
Area code- hone number 7.GROUT. Depth Material Method
---- 2.WEL-L INFORMATION:---- - -- _ w-- -- __ --- ---
From To 2o Ft. r_..... Flow
SITE WELL ID#(if applicable) From To Ft-v7 n A 71 G-S-_
STATE WELL PERMIT#(if applicable) From To Ft.
DWO or OTHER PERMIT#fif applicable). 329rc07 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply�l From To Ft. in. in.
DATE DRILLED &3W021 From To Ft. in. in.
TIME COMPLETED [1i•M AM❑ PM)i] From To Ft.—in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
Depth Size Material
CITY:WARRENSVILLR COUNTY. ASH'R From To Ft.
From To Ft.
OFF HICKORY TRAM OFF HWY 88 OFF HWY.1914 OF 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)
May be in degrees, 0 Q--n ^'AY
LATITUDE 3 minutes,seconds or 99 110 Sft OSTONE
LONGITUDE in a decimal format
Latitude/longitude source: XI GPS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4.WELL OWNER
OWNER'S NAM GM s LINDp, (;p]RFdIGR
STREET ADDRES44 00 MT j �7 SUITE SU 104
r �- z-r—T—zv
State Zip
(f33 )-977-1194
Area code-Phone number
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 600 0.2 5 GPM—.�'--1 9-S1 1?-5 40--S-409
b. DOES WELL REPLACE EXISTING WELL? YES❑ NV
c. WATER LEVEL Below Top of Casing: !ZS 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 P OVIDED TP IE WELL OWNER.
d. TOP OF CASING IS FT.Above Land Surface*
*Top of casing terminated a or below land surface may require
a variance in accordance with 15A NCAC 2C.0118 SIGNATURE OF CERTIFIED WELL CONTRACT 15ATP
e. YIELD(gpm): 2 METHOD OF TEST Air�
PAIA4 NA CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days.Attn: Information Mgt., Form GW=1a
1617 Mail Service Center-Raleigh, NC 27699-1617 Phone No.[phone] ext 568. Rev.7/05
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