GW1-2021-06188_Well Construction - GW1_20211025

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RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
2780. � 210092-
WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: 44
f. DISINFECTION:Type HTH Amount
KEITH PRESNELL
g. WATER ZONES(depth):'
Well Qpj2raQLQC(Inqvidual Name), . From 81 To 82 From 133 To 134
ULWtY Wt IUH I WILL &I'LIMH CU., INC.
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 55 Ft. 6118 .350 PVC
City or Town State Zip Code From To Ft.
( 82$ ) 264-2651 From To Ft
Area code-Phone number 7.GROUT: Depth Material Method
2.WELL INFORMATION: -- From--0-To - Ft 20 _BEtaT_O1=__:_- GtayitV Maw
- -- --- -- -- - - -- . -
SITE WELL ID#(f applicable) From To Ft.246p`GS
STATE WELL PERMIT#(H applicable) From To Ft.
33711*/
DWQ or OTHER PERMIT ilf f applicable) &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable
licable Box): Residential Water Supply From To - Ft. in. in.
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DATE DRILLED From To Ft. in. in.
TIME COMPLETED AM❑ PM L From To Ft. in. in.
9.SAND/GRAVEL PACK:
3.WELL LOCATION:
Depth Size Material
CITY: BOONS COUNTY �� From _To Ft.
OFF PE14LEY RD OFF SAMPSON OFF BLUE RIDGE P 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 45 DIRT
May be in degrees,
LATITUDE 3 _ 36.190426 minutes,seconds or 45 81 BLUE GRANITE
LONGITUDE _ -$1.710471 in a decimal format 81 82 QUARTZICREVICE
Latitude/longitude source: A GPS ❑Topographic map 82 133 BLUE GRANITE
(location of well must be shown on a USGS topo map and 133 134 CREVICE
attached to this form if not using GPS) 134 225 BLUE GRANITE
4.WELL OWNER
OWNER'S NAMENATASHA VO'=
STREET ADDRESS°JOSEPH BRIDGES, PO BOX 3352
BOONE NC 286(Y7
City or Town State Zip Code
(6( 15) 1-293-0033
Area code-Phone number (niQrM3fto_n r0
5.WELL DETAILS: 11.REMARKS: ")VVK �
a. TOTAL DEPTH: 225 7 GPM 91-82 8 dFIM 133- 134
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO)I
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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 CONSTRUqPqN STANDARDS,AND THAT A COPY OF THIS
RE R HAS BE N P OVIDE O HE WELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land Surface* l
Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C.0118 SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
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e. YIELD(gpm): 15 METHOD OF TEST Alt PRINTED NAME OF PERSON CONSTRUCTING THE WELL
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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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