GW1-2021-05904_Well Construction - GW1_20211025

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o RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 2780 210M
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 98
KEITH PRESNELL
g. WATER ZONES(depth):
Well Contractor Individual Name 461 462
( • —•—• •—• �• • From To From To
UtWtY WHIUH I WILL &HUMF UU., INU.
From To From To
Well Contractor Company Name From To From To
STREET ADDRESS P.O.BOX 309 6.CASING: Thickness/
BOONE NC 28607 Depth Diameter Weight Material
From 0 To 103 Ft. 61/4 .188 GrALV
City or Town State Zip Code From To Ft.
( 828 ) 264-2651 From To Ft.
Area code-Phone number 7.GROUT: Depth I Material Method
2.WELL INFORMATION: From 0 To 20 Ft.13ENPONIT Gravity Flow
SITE WELL ID#f applicable) From To Ft A-
(i _ —
STATE WELL PERMIT#(if applicable) From To Ft.
DWO or OTHER PERMIT#(•if applicable) &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Ap licable Box): Residential Water Supply From To Ft. in. in.
DATE DRILLED TOMY2021 From To Ft. in. in.
TIME COMPLETED AM❑ PM From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
Depth Size Material
CITY. LENOIR COUNTY CALDWELL From--To—Ft.
1424 HARVEY PLACE OFF ADAKO RD OFF CO= 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 95 MUD/GRAVEL
35.8W379 May be in degrees, 95 461 GRAY GRANITE
LATITUDE 3 minutes,seconds or
LONGITUDE in a decimal format 451 462 CREVICE
Latitude/longitude source GPS ❑Topographic map 462- SOS GRAY GRANITE
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4.WELL OWNER
OWNER'S NAMEERLY THOMPSON HAYES �
STRF&ffES
11...tN'_.1LVv VV1ittCCNC ..r T 9
City or Town State Zip Code
= 302-5045 'ProcessingkJA
Area code-Phone number ll OSNR$eC 10
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 505 3 GPM 461 -462
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO)b
c. WATER LEVEL Below Top of Casing: 10 FT. I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
(Use"+"if Above Top of Casing) 15A NCAC 2C,WELL CONSTR CTION STANDARDS,AND THAT A COPY OF THIS
O4RD HAS BEEN P OVID 0 THE WELL OW NE
d. TOP OF CASING IS 1 FT.Above Land Surface'
*Top of casing terminated at/or below land surface may require
R '+
a variance in accordance with 15A NCAC 2C.0118 SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
3 Air KEITH PRESNELL
e. YIELD(gpm): METHOD OF TEST
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 5 8.1 Rev.7/05

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