GW1-2021-06691_Well Construction - GW1_20211007

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RESIDENTIAL WELL CONSTRUCTION RECORD
- - C North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 2780 j 210139
1.WELL CONTRACTOR: f. DISINFECTION:Type ;HTH Amount 65
KEITH PRESNELL
g. WATER ZONES(depth):,'
Well QpjgraQJQr I(rldw,i(jualllam�, 327 328
ULWLY ICjH I WELL &PUMP CO., INC. From To From To
From TO From To
Well Contractor Company Name From To From To
STREET ADDRESS P.O.BOX 308 6.CASING: Thickness/
BOONE NC 28607 Depth Diameter Weight Material
From 0 To 70 Ft. 6119 .350 PVC
City or Town State Zip Code From To Ft.
( 09 ).264-2651 From To Ft.
Area code-Phone number
7.GROUT: Depth Material Method
2.WELL INFORMATION: From 0 To 20 Ft.BENTONIT GrsaltyFlow
"SITE WELL ID#(if applicable) From ITo Ft.25 BAGS -
STATE WELL PERMIT#of applicable) From To Ft.
DWO or OTHER PERMIT#(if applicable) 357461 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply From To Ft. in. in.
DATE DRILLED 9/22/2021 From To Ft. in. in.
TIME COMPLETED 03.00 AM❑ PM I] From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
BLA3ATING ROCK Wata�a ;. Depth Size Material
CITY: COUNTY From _To Ft.
OFF JONES MILLER RD OFF AHO OFF HWY 321 From _To Ft.
From To Ft.
(Street Name,Numbers,Communit)&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 DIRT
May be in degrees,
LATITUDE 3 36.153222 minutes,seconds or W 327 BLUE GRANITE
LONGITUDE _ 81.629738 in a decimal format 327 328 QUARTZICREVICE
Latitude/longitude source: N GPS ❑Topographic map 328 330 BLUE GRANITE
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS) �`0y
4.WELL OWNER
OWNER'S NAMESABPMA FAP UNGTON
STREET ADDRES /o CASH CUSTOM HOMES, PO BOX 125 &1
BOONE NC 286d7 5�29
City or Town State Zip Code
(( g28) .1-297-5353 3 Sg 9
Area code-Phone number
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 330 10 GPM 327-328
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO)U
C. WATER LEVEL Below Top of Casing: 20 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 P OVIDED THE WELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land Surface" 3�*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C.0118 SIGNATURE-OF CERTIFIED WELL CONTRACT R DATE
e. YIELD(gpm): 10 METHOD OF TEST Air 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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