GW1-2022-01422_Well Construction - GW1_20220124

RESIDENTIAL WELL CONSTRUCTION RECORD
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North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 2780 } i 210175
1.WELL CONTRACTOR:
KEITH PRESNELL f. DISINFECTION:Type iHTH Amount 90
g. WATER ZONES(depth):'
Well Contractor(Individual Name) From 220 To 220 From TO
IDEV►IEY'WRIGHT WELL &PUMP CO., INC. From TO From To
Well Contractor Company Name From TO From TO
STREET ADDRESS P. O:BOX 308 6.CASING: Thickness/
BOONS NC 28607 Depth Diameter Weight Material
From 0 TO 88 Ft. (5118 .350 PVC
City or Town State Zip Code From TO Ft.
( = )264-2651 From To Ft.
Area code-Phone number
7.GROUT: Depth Material Method
2.WELL INFORMATION:
From 0 To 20 Ft.BENTONIT Gmi Flow
--SITE WELL ID-#(ifapplicable)_- - _ From : To - -Ft.31 BAGS _
STATE WELL PERMIT#(if applicable) From To Ft.
DWO or OTHER PERMIT#(•If applicable) 135702 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply From To Ft. in. in.
DATE DRILLED 12/27/2021 From To Ft. in. in.
TIME COMPLETED 03:00 AM❑ PM KI From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
Depth Size Material
CITY: BOONE COUNTY Wdsg= From To Ft.
351 PINNACLE DR OFF PINNACLE DR OFF HVJ Y 421 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 7g DIRT
May be in degrees,
LATITUDE 3 16.223262 minutes,seconds or 7Q 21(1 GRANITE
LONGITUDE -91.69M2 in a decimal format 21n 238 SHALE
Latitude/longitude source: W GPS ❑Topographic map 23B 340 GRANITE
(location of well must be shown on a USGS topo map and 3d0 360 SHAI E
attached to this form if not using GPS) 0 420. GRANITE
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4.WELL OWNER 420 592 SHAI F
OWNER'S NAMEC AROT,TEA TIT RC 592 am GRARIITF
STREET ADDRES8351 PINNACLE DR_
BOONE NC 28W7
City or Town State Zip Code
1-773-2215
Area code-Phone number ?.!
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: $00 I GPM 220-220
b. DOES WELL REPLACE EXISTING WELL? YES❑ N0)Ir7
c. WATER LEVEL Below Top of Casing: 359 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 PROVIDE THE WELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land Surface' 16
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Top of casing terminated at/or below land surface may require QO
a variance in accordance with 15A NCAC 2C.0118 SIGNATURE OF CERYIFIE ELL CO R DATE
e. YIELD(gpm): 1 METHOD OF TEST Au KEITH PRESNELL
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
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 5&1 Rev.7/05
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