GW1-2021-02060_Well Construction - GW1_20210620

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RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 2780 210017
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 84
KEITH PREENELL g. WATER ZONES(depth):
Well Contractor(Individual Name) From 133 To 134 From 489TO 499
DDAEY'YVRiGH T VVELL &PUMP CO.. INC:. From To From To
Well Contractor Company Name From To From To
STREET ADDRESS F.O.BOX 308 6.CASING: Thickness/
BOONE NC 28607 Depth Diameter Weight Material
From 0 To 90 Ft. 6118 .350 PVC
City or Town State Zip Code From To Ft._
( BU )-264-2651 From To Ft.
Area code-Phone number
7.GROUT: Depth Material Method
2.WELL INFORMATION: From 0 To 20 Ft. BENTONTT &aVityFlow
SITE WELL ID#(ifapplicable) From To Ft. 22BAGS
STATE WELL PERMIT#(if applicable) From To Ft._
DWQ or OTHER PERMIT#(if applicable) 337416 8.SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply iX From To Ft._ in. in.
DATE DRILLED 6/1/2021 From To Ft._ in. in.
TIME COMPLETED 03:00 AM❑ PM From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
Depth Size Material
CITY. SUGAR GROVE COUNTY Wetagua From To Ft.
215 IRA HARMON RD OFF PFn 7 IPS BRANCH OFF 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 An
May be in degrees, 171 RT
LATITUDE 3 N36+07.339 minutes,seconds or Fin 133 GRAY GRANITE
LONGITUDE W081*31,420" in a decimal format 133 13t CREVICE
Latitude/longitude source: CJ(GPS ❑Topographic map 134 d88 R1 I I t.RAY GRANITE
(location of well must be shown on a USGS topo map and 488 d89 BIG CREVICE
attached to this form if not using GPS) 489 AM GLUE GRANITE
4.WELL OWNER
OWNER'S NAME LUCHAEL HARMON
STREET ADDRESS%KENNETH HARMON. 776 BETHEL RD tiv
VII.A.S NC 28692
City or Town State Zip Code 11 IN
( (704) - 414-0589
Area code-Phone number {C!R'3c rr�t7C1
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 500 1 GPM 133- 134 11 GPM 4W-489
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO W
c. WATER LEVEL Below Top of Casing: 100 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 PROVIDED TO T WELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land Surface` %
'Top of casing terminated at/or below land surface may require12 `(ems
a variance in accordance with 15A NCAC 2C.0118 SIGNATURE OF CERTIFIED WELL CONTRAC111513 DATE
e. YIELD(gpm): 12 METHOD OF TEST Air KEITH PRFSNFLL
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 568. Rev.7/05

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