GW1-2021-06602_Well Construction - GW1_20211007

a.;¢STATp o
ti
RESIDENTIAL WELL CONSTRUCTION RECORD
_ �cQ North Carolina Department of Environment and Natural Resources-Division of Water Quality
*•".,,� 210156
•� �„• 2780
WELL CONTRACTOR CERTIFICATION# f ;
1.wEL54
KEITH PRESNELL f. DISINFECTION:Type 'HTH Amount
g. WATER ZONES(depth):
Well ntr r.(ndividual_lam� From 220 To 23I From To
�tVl►t`L YVFdIUH 109LL&PUMP CO., INC.
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 120 D'I er We. ht -Material
From To Ft. OO tt V
PVC
City or Town State Zip Code From To Ft.
( 828 )-264-2651 From To Ft.
Area code-Phone number 7.GROUT: Depth Mat 1� Meaod
2.WELL INFORMATION: From 0 To 20 Ft.BENT'iNIT GraaityYloW
-SITE WELL_ID#(if applicable)__�__ ____ ____�._- -—_.._From---___To--- .--.-Ft��G�
STATE WELL PERMIT#(d applicable) From To Ft.
DWO or OTHER PERMIT#(It applicable) &SCREEN: Depth Diameter Slot Size Material
WELL USE Check A I' : Residential Water Supply( P$1�� >�x) PP Y From To Ft. in. in.
DATE DRILLED From To Ft. in. in.
TIME COMPLETED 03.00 AM❑ PM From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
Depth Size Material
CITY: FLEETWOOD COUNTY ASHE From -TO—Ft.-
OFF WINDY ACRES RIDGE RD OFF WINDY HILL R 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 60 CLAY
May be in degrees,
LATITUDE 3 _ 36.309392 minutes,seconds or 60 9D SANDSTONE
LONGITUDE -81.500097 in a decimal format 90 220 GRANITE
Latitude/longitude source: CMGPS ❑Topographic map 220 221 CREVICE-.
(location of well must be shown on a USGS topo map and 221 320-- GRANITE
attached to this form if not using GPS)
4.WELL OWNER
OWNER'S NAMENOLAN HUFF
STREET ADDRESS419 WINDY ACRES RIDGE RD.
FLEETWOOD NC 28628
City or Town State Zip Code
( (469) )_ 245-9301 Q ��
,t
Area code-Phone number -�proGRSStC1�Q
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 320 2 GPM 220-221
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO'XI
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 NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
RE ORD HAS BEEN PROVIDE 0 THE WELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land Surface' 9
Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C.0118 SIGNATURE OF CERTIFIED WELL CONTRAQTGR DATE
e. YIELD(gpm): 2- METHOD OF TEST Air KEITH PRESNEI 1!
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
M
Submit the original to the Division of Water Quality within 30 days.Attn:Information Mgt., Form GW-1 a
1617 Mail Service Center-Raleigh, INC 27699-1617 Phone No.[phone] ext 566.a Rev.7/05
,i

I
- .
• ,•, ,, �, J-e � ��� . _ -a .� � .fig..�1__.. ., 5..+
!
S`
t