GW1-2021-06689_Well Construction - GW1_20211007

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RESIDENTIAL WELL CONSTRUCTION RECORD
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North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 2780 210104
1.WELL CONTRACTOR:
KEITH PRESNELL f. DISINFECTION:Type HTH Amount 142
g. WATER ZONES(depth):
Well Contractor(Individual Name) From 291 To 292 From 777 To 778
DEVVEY WhdiGH T 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 2860 Depth Diameter Weight Material
From 0 To . 65 Ft. 61/8 .350 PVC
City or Town State Zip Code From To Ft.
( 828 )-264-2651 From To Ft.
Area code-Phone number
2.WELL INFORMATION: 7.GROUT- Depth Material Method
From 0 To 20 Ft.BENTONrr Gravity Flow
SITE WELL ID#(if applicable)' _ From To Ft.
STATE WELL PERMIT#of applicable) From To Ft.
DWO or OTHER PERMIT#(If applicable) 328023 8.SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply From To Ft. in. in.
DATE DRILLED 9114i2021. From To Ft. in. in.
TIME COMPLETED 03:00 AM❑ PM I From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
Depth Size Material
CITY: BLOWING ROCK COUNTY Wa al= From To Ft.
BLUE RIDGE MTN CLUB OFF LAURELMORE PKWY 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 55 DIRT
_ _ 36.158529 May in degrees,
LATITUDE 3 minutes,seconds or 55 291 GRAY GRANITE
LONGITUDE -91.5979M in a decimal format 291 292 CREVICE
Latitude/longitude source: I GPS ❑Topographic map 292 777 13WEIGRAY GRANITE
(location of well must be shown on a USGS topo map and 777 778 , QUARTZ/CREVICE
attached to this form if not using GPS) 778 805 BLUE GRANITE
4.WELL OWNER
OWNER'S NAMETIMOTHY&STE FI NM ROBERTS
STREET ADDRESS°TOM EGGERS CONSTRUCTION, 9872 - ®�
BANNER ELK NC 28604 n��1
City or Town State Zip Code
(9( 10) ) 950-9109
Area code-Phone number n U-\OX-
5.WELL DETAILS: 11.REMARKS: `rE3�� Q�N
a. TOTAL DEPTH: 805 1 GPM 291 -292 1 GPM T77-778
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 NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
RECORD HAS BEIENPROVIDEDMI
HE 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 OF CERTIFIED WELL CONTRACYPM DATE
e. YIELD(gpm): 2 METHOD OF TEST Aar 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-1 a
1617 Mail Service Center-Raleigh,INC 27699-1617 Phone No.[phone] ext 568. Rev.7/05
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