GW1-2021-06600_Well Construction - GW1_20211007

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e;¢STATE 4 iC i
RESIDENTIAL WELL CONSTRUCTION RECORD
�C North Carolina Department of Environment and Natural Resources-Division of Water Quality
•� WELL CONTRACTOR CERTIFICATION# 7780 I 210167
1.WELL CONTRACTOR: T i
KEITH PRESNELL f. DISINFECTION:Type IHTH Amount 123
g. WATER ZONES(depth)>
Well Contractor(Individual Name) From 600 To 601 From To
t9tYVtY WKIEiHt WMtLL lip.IaUMIa tU., INt.
From To From To
Well Contractor Company Name From To From To
P.O.BOX 308
STREET ADDRESS 6.CASING: Thickness/
BOONE NC 28607, 0 Depth Diameter Sight PVC
Material
From To 66 Ft. 118 V
City or Town State Zip Code From To Ft.
( SM )264-2651 From To Ft.
Area code-Phone number
2.WELL INFORMATION: 7.GROUT: Depth Material Method
From 0 To 20 Ft.BENTONIT Gt>;vityFlow
--SITE-WELL ID#(ifapplicable)- — From TO -- - Ft;_1$BkGS
STATE WELL PERMIT#(if applicable) From To Ft.
DWQ or OTHER PERMIT#(if applicable) 152288 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply From To Ft. in. in.
DATE DRILLED 9/9/2021 From To Ft. in. in.
TIME COMPLETED 03.00 AM❑ PA From To Ft. . in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
GIANDALE SPRINGS 1qSBE Depth Size Material
CITY: COUNTY From To Ft.
220 WE5I VALE KNOB OFF CHERRY HELL RD OFF P 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 15 DIRT
36.357651 May be in degrees, 15 EO CLAY
LATITUDE 3 minutes,seconds or
LONGITUDE in a decimal format so ISM . GRANITE
Latitude/longitude source: 21 GPS ❑Topographic map 600 601 CREVICE
(location of well must be shown on a USGS topo map and 601 GRANITE
attached to this form if not using GPS)
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4.WELL OWNER e
OWNER'S NAMECHARTES IMTCHELL
STREET ADDRESSPO BOX 11 IMt
GLENDALE SPRINGS NC 28629 -
City or Town State Zip Code r poti
(3( 36) 1-982-2649 WWI O
Area code-Phone number
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 800 0.5 GPM 600-601
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOXI
c. WATER LEVEL Below Top of Casing: 180 FT. 1 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
REC RD HAS BEEN R VIDED THE WELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land Surface*
*Top of casing terminated at/or below land surface may require `
a variance in accordance with 15A NCAC 2C.0118 SIGNATURE OFfCERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): 0.5 METHOD OF TEST Air KEITH PRESNELL
PRINTED NAME OF PERSON 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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