GW1-2022-01927_Well Construction - GW1_20220224

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RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
2780 i 210172
WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 49
KEITH PRESNELL
g. WATER ZONES(depth):'
Well Contractor(Individual Name) From 196 To 201 From To
DEVVEY WR GH T YELL &PUMP CO., INC. From 284 To 285 From To
Well Contractor Company Name From To From To
STREET ADDRESS P.O.BOX 308 6.CASING: Thickness/
BOONE NC 28607 Depth Diameter Weight Material
From 0 To 125 Ft. 6I/8 .350 PVC
City or Town State Zip Code From To Ft.
( 8W )264-2651 From To Ft.
Area code-Phone number 7.GROUT- Depth Material Method
2.WELL INFORMATION: From 0 To 20 Fi.BENTONIT &avityFlow
SITE WELL ID#(if applicable) From To Ft.2BA.G�-
- --- -----—--- —
STATE WELL PERMIT#(if applicable) From To Ft.
DWQ or OTHER PERMIT#(if applicable) 330640 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply® From To Ft. in. in.
DATE DRILLED 211/2022 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: SST' JEFFMSON COUNTY ASHE From _To Ft.
#775 PVT DR OFF BARE RD OFF 163 OFF IDLEWMD From _To Ft.
From To Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) A
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
❑Slope ❑Valley ❑Flat ❑Ridge ❑Other From To Formation Description
(check appropriate box) f1 11S nIR_T
May be in degrees,
LATITUDE 3 363 A7SO minutes,seconds or 115 195 GRANITE
LONGITUDE -81.389076 in a decimal format JQ;; 201 ` 01IARTZ
Latitude/longitude source: (R GPS ❑Topographic map ?f11 7RA GRANITE
(location of well must be shown on a USGS topo map and 284 285 kMIn
attached to this form if not using GPS) 7135 305 GRANITE
4.WELL OWNER
OWNER'S NAMETATYANA C'TIURCIRT)
STREET ADDRESSI$1 COT T-CRRRRK--R_1]-, _
ANCMG C 2$643 _
City or Town State Zip Code
(( 973) -534-W91
Area code-Phone number
5.WELL DETAILS: 11.REMARKS: toj'K lj'.
a. TOTAL DEPTH: 305 7('Ipm 196-71)l
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO)
C. WATER LEVEL Below Top Of Casing: 60 FT. I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
(Use"+"if Above Top of Casing) 15A NCAC 2C,WELL CONSTRUC STANDARDS,AND THAT A COPY OF THIS
RECORD HAS BEE PR VIDED 0 T E WELL OWNER.
d. TOP OF CASING IS I FT.Above Land Surface'
"Top of casing terminated at/or below land surface may require i �r
a variance in accordance with 15A NCAC 2C.0118 SIGNATURE OF CE IFIED LL CONTRACTOR DATE
e. YIELD(gpm): 10 METHOD OF TEST Air PRINT AM CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days.Attn:Information;Mgt., Form GW-ia
1617 Mail Service Center-Raleigh,NC 27699-1617 Phone No.[phone] ext 568. Rev.7/05

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