GW1-2021-07492_Well Construction - GW1_20211116

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RESIDENTIAL WELL CONSTRUCTION RECORD
c° North Carolina Department of Environment and Natural Resources-Division of Water Quality
2780 210134
WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 30
KEITH PRESNELL
g. WATER ZONES(depth):
Well Contractor(Individual Name) From 122 To 124 From To
0EWEY WRiGH T WELL&PUMP CO., INC. From To from To
Well Contractor Company Name From To From To
STREET ADDRESS P.O.BOX 30$ 6.CASING: Thickness/
BOONS NC 28607 Depth Diameter Weight Material
From 0 To 92 Ft. 61/8 .350 PVC
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.BE14TONTT Gravity Floes
____ __ ._--._-. _ _
_ —SITE-VVEL- I (if applicable) From To Ft.35BA�Sr —
STATE WELL PERMIT#(if applicable) From To Ft.
DWQ or OTHER PERMIT#(if applicable) 146171 8.SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply From To Ft. in. in.
DATE DRILLED 11/5/2021 From To Ft. in. in.
TIME COMPLETED 03:00 AM❑ PM kb From To Ft. in. in.
9.SAND/GRAVEL PACK:
3.WELL LOCATION:
WEST.I�'TR.SON psi Depth Size Material
CITY: COUNTY From To Ft.
LOT 9 PARKWAY POINTE OFF PARKWAY POINT O From _To Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) From To Ft.
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
❑Slope ❑Valley ❑Flat ❑Ridge ❑Other From To Formation Description
(check appropriate box) 0 60 DIRT
36 287790 May to ,s degrees,coeds o 60 76 SHALE
LATITUDE 3 minutes,seconds or
LONGITUDE -81.423758 in a decimal format 76 122 GRANITE
Latitude/longitude source:- GPS ❑Topographic map 122 124 QUARTZ/VOID
(location of well must be shown on a USGS topo map and 124 176 GRANITE
attached to this form if not using GPS) 176 182 SHALE
4.WELL OWNER 182 205 GRANITE
OWNER'S NAMETERESA PAGE/WU PLLC
STREET ADDRESS145 ROCKY MOUNT RD. - ___ [�f
BOONE NC 28607 —
City or Town State Zip Code Q21
(( 8= )-964-1334 14
Area code-Phone number MRsalay
5.WELL DETAILS: 11.REMARKS: Uffr
a. TOTAL DEPTH: 205 20 GPM 122-124
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO)U
C. WATER LEVEL Below Top of Casing: 60 Fr. I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
(Use"+"if Above Top of Casing) 15A NCAC 2C,WELL CON TRUCT STANDARDS,AND THAT A COPY OF THIS
RECO D HAS BEEN RO DED T E WELL OWNER2:feORIL
d. TOP OF CASING IS 1 FT.Above Land Surface* L /
*Top of casing terminated at/or below land surface may require e$
a variance in accordance with 15A NCAC 2C.0118 SIGNATURE OF C IFIED ELL C NTRADATE
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

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