GW1-2021-05887_Well Construction - GW1_20211025

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RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# I 1
1.WEL TRH ��t HTH 108
�CEN PREAELL If. DISINFECTION:Type Amount
g.,1K JjF �NES(depth):'
WellWK9V WMMMLL&PUMP CO., INC. From To From To
From To From To
Well Contractor Company Name From To From To
P.O.BOX 308
STREET ADDRESS 6.CASING: Thickness/
BOONE NC 28607 Depth Diameter Weight Material
From To Ft.
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 To Ft.
SITE WELL ID#(if applicable) From To Ft.
STATE WELL PERMIT#(if applicable) 145463 From To Ft.
DWQ or OTHER PERMIT#(if applicable) &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable
licable Box): Residential Water Supply From To Ft. in. in.
�
DATE DRILLED From To Ft. in. in.
TIME COMPLETED AM❑ PM From To Ft. in. in.
9.SAND/GRAVEL PACK:
3.WELL LOCATION:
DRMLDEEPER ASHE Depth Size Material
CITY.. COUNTY From To Ft.
M9 TURKEY RIDGE OFF BENT RIVERDR OFF SU A 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) 0 400 EXISTING WELL
LATITUDE 3 minutteos,seconds or
36.494213 May in degrees, 400 5m GRANITE
LONGITUDE -8F4W06 in a decimal format 5W 532 QUARTZ
Latitude/longitude source: IN GPS ❑Topographic map s 600 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 NAMET ESL1E LEONARD
STREET ADDRES 31 KLUTZ , r-T
MOO NG n
28115 ynit
City or Town State Zip Code fn n f]IQCB ,011.-d
((704) )_458-2222 MOR
Area code-Phone number
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 600 0.5 GPM UNKNOWN:-
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOXI
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 CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
RE D HAS BEEN PROVI ED TO E WELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land Surface*
" , W
Top of casing terminated at/or below land surface may require AIGNAT
a variance in accordance with 15A NCAC 2C.0118 E OF CERTIFIED_;WELL CONTR C R DATE
e. YIELD(gpm): 0.5 METHOD OF TEST Air 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,NC 27699-1617 Phone No.[phone] ext 568! Rev.7/05
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