GW1-2022-01949_Well Construction - GW1_20220224

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. S RESIDENTIAL WELL CONSTRUCTION RECORD
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North Carolina Department of Environment and Natural Resources-Division of Water Quality
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WELL CONTRACTOR CERTIFICATION#
1.WEL i HTH 70
�C� ffi�ETNELL f. DISINFECTION:Type ! Amount
g. WATER2j?NES31jpth)`.
Well t ra i YYKIiftLL &PUMP CO., iNC. From To From TO
wt�ilaH I From To From To
Well Contractor Company a�1e
t�.SOX 308 From To From To
STREET ADDRESS 6.CASING: I Thickness/
Depth Diameter Weight Material
BOONS NC 28607 From u To 2A Ft. 01/4 Aaw 6
City or Town State Zip Code From To Ft.
( SW )-264-2651 From To Ft.
Area code-Phone number
2.WELL INFORMATION: 7.GROUT: Depth Material Method
From 0 To 20 Ft.BENTONIT Gravity Flow
_ SITE WELL ID#(itappncable) _. _ _ _ -- From To Ft:`18BAGS
STATE WELL PERMIT#(if applicable) From - To Ft.
DWQ or OTHER PERMIT#(if applicable) 273572 S.SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply From To Ft. in. in.
DATE DRILLED 2/8/2022 From To Ft. in. in.
TIME COMPLETED 03:00 AM❑ PM ) From To Ft. in. in.
3.WELL LOCATION: 9.SAND/GRAVEL PACK:
Depth Size Material
CITY: BOONE COUNTY Watawa From To Ft.
OFF SLEEPY VALLEY OFF I RISEML OFF BOONE R 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 49 DIRT
May be in degrees,
LATITUDE 3 36.20M minutes,seconds or 49 196 GRANITE
LONGITUDE _ in a decimal format 196 230 SHALE
Latitude/longitude source: (A GPS ❑Topographic map 230 238 QUARTZ
(location of well must be shown on a USGS topo map and 238 365 j GRANITE
attached to this form if not using GPS) 365 368 QUARTZ
4.WELL OWNER 368 425 GRANITE
OWNER'S NAMEEMMA NAVARRO&JUANANTONIO AR
STREET ADDRESS150 SUMMER DR,-LOT 20 -
BOONE NC 28607 �i ��14
City or Town State Zip Code P R ft T• d
(( SM -964-7322 FER4 9
Area code-Phone number
5.WELL DETAILS: 11.REMARKS: i'Wi+ 'E 1WRI,f FLd
a. TOTAL DEPTH: 425 3 GPM 265-368 WIM, Wrhl Rr"I ,Ea. K Vill
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOR 3
c. WATER LEVEL Below Top of Casing: 80 FT. I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
(Else"+"if Above Top of Casing) 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
RECORD HAS BEEN JP VIDEM THE WELL OWNER. _
d. TOP OF CASING IS 1 FT.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 CONTRA TOR DATE
e. YIELD(gpm): 3 METHOD OF TEST Air KEITH PRESNFL 1�
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
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Submit the original to the Division of Water Quality within 30 days.Attn: Information Mgt., Form GW-1 a
1617 Mail Service Center-Raleigh, INC 27699-1617 Phone No.[phone] ext'68. Rev.7/05
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