GW1-2021-07487_Well Construction - GW1_20211116

STATE o
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
2780 200149
WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 35
KEITH PRESNELL
g. WATER ZONES(depth):'
Well[�ntr of IWkIIV�INVY LL &PUMP CO., INC. From 174 To l b From To
LU1�t YY Wk YYt From To From To
Well Contractor Company Name P.0.BOX 30$ From To From To
STREET ADDRESS 6.CASING: Thickness/
BOONE NC 28607 Depth Diameter Weight Material
From 0 To 60 Ft. 61/8 .350 PVC
City or Town State Zip Code From To Ft.
( 82$ )264-2651 From To Ft.
Area code-Phone number
2.WELL INFORMATION: 7.GROUT: Depth Material Method
From 0 To 20 Ft.BENTOMT Gravity Flow
_..__ SITE WELL-iD-#(if applicable)-- -- -- --_____ -.- --- - From- - To -- - Ft:32BAGS—___
STATE WELL PERMIT#(if applicable) From To Ft.
DWQ or OTHER PERMIT#(if applicable) 154672 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply From To Ft. in. in.
DATE DRILLED 11/4/2021 From To Ft. in. in.
TIME COMPLETED 03:00 AM❑ PM I From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
Depth Size Material
CITY: TODD COUNTY ASHfi From To Ft.
233 HOLMAN RD HWY 194 OFF HWY 221 OFF HWY From _To Ft.
From To Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG QQII// 66��
I]Slope ❑Valley ❑Flat ❑Ridge ❑Other From To Formation Descn Idnl
(check appropriate box) 0 52 DIRT
May be in degrees,
LATITUDE 3 N36;12.905 minutes,seconds or 52 120 GRAM! i
LONGITUDE W081*31.73$ in a decimal format 120 128 SHALE Rp re A+i'
Latitude/longitude source: M GPS ❑Topographic map 128 174 _ GRANITE
(location of well must be shown on a USGS topo map and 174 176 QUARTZ
attached to this form if not using GPS) 176 205, GRANITE
4.WELL OWNER
OWNER'S NAMEJANICE E=
STREET ADDRESS420 HOLMAN RD,
TODD NC 28694
City or Town State Zip Code
(( $M )-726-7559
Area code-Phone number
S.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 205 20 GPM 174-176
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO*]
c. WATER LEVEL Below Top of Casing: 40 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
RECORD HAS BEEN P OVIDED O HE WELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land Surface* t
*Top of casing terminated atlor below land surface may require `-��
a variance in accordance with 15A NCAC 2C.0118 SIGNATURE OF CERTIFIED WELL CONT OR DATE
e. YIELD(gpm): 20 METHOD OF TEST Air KEITH PRESNELL
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
I
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
i
i
i

,
_+A
ri :.