GW1-2021-02057_Well Construction - GW1_20210620

d c STATE u
RESIDENTIAL WELL CONSTRUCTION RECORD
V A
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 2780 210038
1.WELL CONTRACTOR:
KEITH PRESNELL f. DISINFECTION:Type HTH Amount 138
g. WATER ZONES(depth):
Well Contractor(Individual Name) From 513 To 514 From 900TO 970
DEVVEY'ARIGHT WELL &PUMP CO., INC.
From To From To
Well Contractor Company Name From To From To
STREET ADDRESS P.O.SOX 308 6.CASING: Thickness/
BOONE NC 28W7 Depth Diameter Weight Material
From b To Ft. 0 Itb ]3b l++tb
City or Town State Zip Code From To Ft. _
( 828 )- 254-2651 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#(if applicable) From To Ft. 42 BAGS
STATE WELL PERMIT#(if applicable) From To Ft._
DWQ or OTHER PERMIT#(if applicable) 135477 8.SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply�x From To Ft —in. in.
DATE DRILLED 97/2021 From To Ft._ in. in.
TIME COMPLETED 03:00 AM❑ PM From To Ft. in. in.
9.SAND/GRAVEL PACK:
3.WELL LOCATION:
Depth Size Material
CITY: VILAS COUNTY WStagm From To Ft.
620 NEW HOLFISTRAD DR OFF MEADOW LARK W 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) 0 110 DIRT
May be in degrees,
LATITUDE 3 N36+33.446 minutes,seconds or 110 513 GRAY/SLUEGRANITE
LONGITUDE W081+47.266 in a decimal format 513 514 CREVICE
Latitude/longitude source: DGPS ❑Topographic map 514 900 _ BLUE GRANITE
(location of well must be shown on a USGS topo map and 900 970 BLUE GRANITE/WATE
attached to this form if not using GPS)
4.WELL OWNER
OWNER'S NAME ROBERT RIKER 2 r Iv '
STREET ADDRESS 620 NEW HOMESTEAD DR,
VU.AS NC 28692 _ I I n 7091
City or Town State Zip Code
( f8= - 297-7115 ttinn Processing �nl
Area code-Phone number
p�,JP Seci'on
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 970 1 GPM 513-514 0.5 GPM 9W-970
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO I _
c. WATER LEVEL Below Top of Casing: M 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 HA�BEENPR VIDED TITHE WELL OWNER.
d. TOP OF CASING IS FT.Above Land Surface' 1 �ii�[/)
Top of casing terminated at/or below land surface may require 1-1 1
a variance in accordance with 15A NCAC 2C.0118 SIGNAT RE OF CERTIFIED WELL CON OR DATE
e. YIELD(gpm): 1.5 METHOD OF TEST Air KEITH PRFSNPLL-
I
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
1,
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

x
7
AffiVP %�
05
' P�