GW1-2021-06585_Well Construction - GW1_20211029

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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 210083
1.WELL CONTRACTOR:KEITH PRESNELL �HTH
f. DISINFECTION:Type Amount 26
g. WATER ZONES(depth):
Well Contractor(Individual Name) From 128 To 130 From 167 To 168
UEVVEY YVRiGH T WELL&PUMP CO., INC;. From To i From To
Well Contractor Company Name From TO From TO
STREET ADDRESS P.O.BOX308 6.CASING: Thickness/
BOONE NC 2$60l'j Depth Diameter Weight Material
From 0 To---2'Z Ft. 6118 350 13yC
City or Town State Zip Code From To Ft.
( 828 )264-2651 From To Ft.
Area code-Phone number
2.WELL INFORMATION: 7.GROUT: Depth Material Method
From 0 To 20 Ft.RENTOWIT C;rqVitVEIj=
SITE WELL ID#(if applicable) _ From--..__To___ _.Ft. & —
STATE WELL PERMIT#(if applicable) From To Ft.
DWO or OTHER PERMIT#of applicable) 336572 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply 1 From To Ft. in. in.
DATE DRILLED 10/20/2021 From TO Ft. in. in.
TIME COMPLETED 03:00 AM❑ PM X1 From To Ft. in. in.
3.WELL LOCATION: 9.SAND/GRAVEL PACK:
Depth Size Material
CITY: JEFFER' SON COUNTY ASM From To Ft.
LOT 29 OFF JAM BT—kMMURN RD OFF S MMN ST/ From _To Ft.
From To Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
❑Slope ❑Valley ❑Flat ❑Ridge ❑Other From To Formation Description
(check appropriate box) n R1 C1IR,T
May be in degrees,
LATITUDE 3 _ :tA S minutes,seconds or 81 128 GRANITE
LONGITUDE _ _ -RI-422799 in a decimal format 12B 1an 01 IART7
Latitude/longitude source: IR GPS ❑Topographic map.,. 130 167 GRANITE
(location of well must be shown on a USGS topo map and 167 168 i voi 'A+
attached to this form if not using GPS) 168 205 GRANITE
4.WELL OWNER
OWNER'S NAMEMHN FRANIMONj
cce$st
STREETADDRES9y AIISSTFRt_R11FT C${_i.T.(__ ___DO BOX.-134
sea,,
City or Town State Zip o e
(036) )-877-7735
Area code-Phone number
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 205 S C'TTJMA 128- 130 10 G d 167- 368
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOS]
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c. WATER LEVEL Below Top of Casing: 80 FT I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
(Use"+"if Above Top of Casing) 15A NCAC 2C,WELL CONSTRUC STANDARDS,AND THAT A COPY OF THIS
"HASOVIDE O E WELL OWNER.d. TOP OF CASING IS 1 FT.Above Land Surface` 0)� ITop of casing terminated at/or below land surface may requireVA a variance in accordance with 15A NCAC 2C.0118 IFIE I ELL CONTRACTOR' DATE
e. YIELD(gpm): 15 METHOD OF TEST .Aires 1
PRIN M O CONSTRUCTING THE WELL
E
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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