GW1-2022-01421_Well Construction - GW1_20220124

5rATt6� !.
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 2780 i 200206
1.WELL CONTRACTOR:
KEITH PRESNELL f. DISINFECTION:Type IHTH Amount 109
g. WATER ZONES(depth):
Well Contractor(Individual Name) From 320 To 360 From To
GE�/Eir Y1+kiOHT VyELL &PUMP CO., INC. From To From To
Well Contractor Company Name From To From To
STREET ADDRESS P.0.BOX 308 6.CASING: Thickness/
BOONE NC 28607 Depth Diameter Weight Material
From 0 To 100 Ft. cS 118 .350 PVC
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.WELL INFORMATION: From—0 To 20 Ft.BENTONIT GravityFlow
SITE WELL ID#(ifapplicable) From To F.t.20BAGS
STATE WELL PERMIT#(if applicable) From To Ft.
DWQ or OTHER PERMIT#(if applicable) 275760 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply® From To Ft. in. in.
DATE DRILLED 12/21/2021 From To Ft. in. in.
TIME COMPLETED 03:00 AM❑ PM XI From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
Depth Size Material
CITY: FOSCOE COUNTY WAT�PItA From To Ft.
OFF TIOGA RD OFF TWIN RIVERS DR OFF HWY 105 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)
May be in degrees, 0 92 ❑IRT
LATITUDE 3 N36*09486 minutes,seconds or 92 321) GRANITE
LONGITUDE W081+44.531 in a decimal format 320 360 SHALE
Latitude/longitude source: N GPS ❑Topographic map 350 480 GRANITE
(location of well must be shown on a USGS topo map and 480 SIM. SHALE
attached to this form if not using GPS) SIX 605_ GRANITE
4.WELL OWNER
OWNER'S NAMEEDWARD VISON
STREET ADDRESA DOUG MCGUIRE CONSTRUCTION, PO B
BOONE NC 2 W
City or Town State Zip Code
Area code-Phone number q "
5.WELL DETAILS: 11.REMARKS: -JAN 6 4 2G"
a. TOTAL DEPTH: 605 1.5 GPM 320-360
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO%)
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
RECORD HAS BEE OVIDW TO THE WELL OWNER.
t 1
d. TOP OF CASING IS 1 FT.Above Land Surface' ( 1 /
*Top of casing terminated at/or below land surface may require Al Zd / (J�(
a variance in accordance with 15A NCAC 2C.0118 SIGNATURE OF CERTIFIED WELL CONTFbIcCTOR DATE
e. YIELD(gpm): 1.5 METHOD OF TEST Air PRINTED NAME OF PERSON CONSTRUCTING THE WELL
F
t ..
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.(919)7334015 ext 56l8.j Rev.7/05

e-(
- -- --
e.