GW1-2021-07104_Well Construction - GW1_20210915

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j RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 2780 1 210003-2
1.WELL CONTRACTOR:-KEITH PRESNELL HTH - 126
f. DISINFECTION:Type Amount
g. WATER ZONES(depth):
Well Contractor(individual Name) From 620 To 621 From To
DEWEY MIGHT WELL&PUMP CO., INC.
From To From To
Well Contractor Company Name From To From To
STREET ADDRESS P.O.BOX 30$ 6.CASING: Thickness/
BOONE NC 2WIN Depth Diameter Weight Material
From 0 To 40 Ft 61/8 .350 PVC
City or Town State Zip Code From To Ft.
-264-2651 From To Ft.
Area code-Phone number
7.GROUT: Depth Material Method
2.WELL INFORMATION:
From A Tom_ Ft.BENTON= Gravity Flow
- --- --
SITE WELL ID#(if applicable) � � --'--� - From -To "Ft.-.16-BAGS— - - -- - ---
STATE WELL PERMIT#(if applicable) From To Ft.
DWO or OTHER PERMIT#(dapplfcable) 131818 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply 09 From To Ft. in. in.
DATE DRILLED 8/31/2021 From To Ft. in. in.
TIME COMPLETED 03•00 AM❑ PM From To Ft. in. in.
9.SAND/GRAVEL PACK:
3.WELL LOCATION:
Depth Size Material
CITY: BOONE COUNTY WaRgUA From To Ft.
875 PINE-BRANCH RD OFF HARDIN RD OFF HWY 4 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 25 DIRT
May be in degrees,
LATITUDE 3 N36*12.522 minutes,seconds or 25 .30 SANDSTONE
LONGITUDE _ _ W081*42.388 in a decimal format 30 300 GRANITE
Latitudeflongitude source: 2 GPS ❑Topographic map 300. 350 GRANITEIQUARTZ MI)
(location of well must be shown on a USGS topo map and 360 620- - GRANITE
attached to this form if not using GPS) 620 621 CREVICE
4.WELL OWNER 621 700 GRANITE
OWNER'S NAMEDAVID&JUDY EGGERS
STREET ADDREss8-75-PINE-BRANCH RD.
BOONE, NC 2860? `.`•
City or Town State Zip Code `►'�
( (8= -406-1367 c C D
Area code-Phone number
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5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 700 1 GPM 620-621 (3t11
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOXI
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c. WATER LEVEL Below Top of Casing: 60 FT. I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
(Use"+"if Above Top of Casing) 15A NNCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
R RD HAS BEEN PR VIDED O' WELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land Surface`
*Top of casing terminated at/or below land surface may require `ESL
a variance in accordance with 15A NCAC 2C.0118 SIGNATURE OF CERTIFI D ELL CON AC DATE
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e. YIELD(gpm): 1 METHOD OF TEST Air KEITH PREENEIL Lf
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.7/05
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