GW1-2022-01229_Well Construction - GW1_20220103

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RESIDENTIAL WELL CONSTRUCTION RECORD
o North Carolina Department of Environment and Natural Resources-Division of Water Quality
2780 j 210161-2
WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 70
KEITH PRESNELL
g. WATER ZONES(depth):
Well Contractor(Individual Name) 286 294
01-=1 EY�RiGHT SELL&PUMP CO., INC. From To From To
From To From To
Well Contractor Company Name From To From To
STREET ADDRESS p O.BOX 30$ 6.CASING: Thickness/
BOONE NC 28607 Depth Diameter Weight Material
From 0 To 38 Ft. 61/8 .350 I7TC
City or Town State Zip Code From To Ft.
( 828 )264-2651 From To Ft.
Area code-Phone number
7.GROUT: Depth Material Method
2.WELLINFORMATION: From 0 To 20 FtBENTONIT Gravity Flow
SITE WELL ID#(if applicatle) -- -' - -_ `From --- To --
STATE WELL PERMIT#(if applicable) From To Ft.
DWQ or OTHER PERMIT#(if applicable) AG WELL 8.SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply From To Ft. in. in.
DATE DRILLED 121&2021 t� From To Ft. in. in.
TIME COMPLETED AM❑ PM LI From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
BANNM= W saga Depth Size Rprpt'�� :n'
CITY: COUNTY �`�`i"� From To Ft. W.'-f
OFF SHAWNEE RD OFF ANDY HICKS RD OFF WOR From _To Ft. . AN 0 3 292?
From To Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code)
010 SECTIM
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG ROWT01 Fi!UCCESSrdG U1 IF
❑Slope ❑Valley ❑Flat Ll Ridge ❑Other From To Formation Description
(check appropriate box) 0 30 DIRT
May be in degrees, 30 190 GRANITE .
LATITUDE 3 minutes,seconds or
LONGITUDE in a decimal format 190 210 i SHALE
Latitude/longitude source: A GPS ❑Topographic map 210 286 j GRANITE .
(location of well must be shown on a USGS topo map and 285 294 QUARTZ
attached to this form if not using GPS) 294 350 GRANITE
4.WELL OWNER 360 372 i SHALE
OWNER'S NAME70HNRICHARD CITLLEN 372 405 GRANITE
STREET ADDRES;1°M17-PAKLLC. 3175 COLUMBIA AVE NW
FORT LAUD
City or Town State Zip Code
(( 954) 1 520-3614
Area code-Phone number
5.WELL DETAILS: 405 11.REMARKS: -
a. TOTAL DEPTH: yy��,
294
b. DOES WELL REPLACE EXISTING WELL? YES❑ NA
60
c. WATER LEVEL Below Top Of Casing: 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
1 RECORD HAS BEEN P OVID O THE WELL OWNER.
d. TOP OF CASING IS Fr.Above Land Surface*
*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
e. YIELD(gpm): 4 METHOD OF TEST `ir 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-1a
1617 Mail Service Center-Raleigh,NC 27699-1617 Phone No.[phone] ext 568 Rev.7/05
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