GW1-2021-02432_Well Construction - GW1_20210527

.: RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
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WELL CONTRACTOR CERTIFICATION# 2780 ! 20=
1.WELL CONTRACTOR: f. DISINFECTION:Type 1HTH_ Amount
KEITH PRESNELL �
g. WATER ZONES(depth)::
Well Contractor(Individual Name) From 736 To 787 From TO
DtV1EY VV iGH I VV LL PUMP LU., INC:. From TO From TO
Well Contractor Company Name From To From TO
STREET ADDRESS P.O.BOX 308, 6.CASING: Thickness/
Depth Diameter Weight Material
BOONE NC 2$6011. From To Ft. 6 t 4S 35 fit"
City or Town State Zip Code From To Ft.
(M -264-2651 From To Ft.
Area code-Phone number 7.GROUT: Depth Material Method
2.WELL INFORMATION:
From_0 To--_IQ Ft. ARW0Wrr... s$aujitiFlnm
SITE-WELL-ID-#(if.applicable)— --- --- --- - - ---From - To- - - Ft.-22 EAJDS -- - -- - -_
STATE WELL PERMIT#(if applicable) From To Ft.
DWO or OTHER PERMIT#(if applicable) 10743 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply Lx From To Ft. in. in.
DATE DRILLED 5/12/2021 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: BAN14ERELX COUNTY AVERY From To Ft.
From To Ft.
-LOT S-61 OFF SILVER EAGLE TRAIL OFF GOLDEN 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)
May be in degrees, -0 21
LATITUDE 3 p���Trr��� minutes,seconds or 21r--M GREY GRANITE
LONGITUDE txTnit7•zz'T7t in a decimal format 7116-797 BIG GfkE AGE
Latitude/longitude source: WPS ❑Topographic map 7W 790 env i4oeia�T�
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4.WELL OWNER Its
OWNER'S NAME B1FOS•FERr �
STREET ADDRESSuA SKy HolIgg Co MpANV. 2g74TYN Ac,
� 7 2021
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or own State Zip COW
( r -��o_a»s gtsiration Prceessing
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Area code-Phone number QVvR Sepon
5.W ELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 790 SO GMA 'tag[ ^to^+
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO
c. WATER LEVEL Below Top of Casing: 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 TqqHE WELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land Surface* 1 a i & 1/1 �� (1 /
*Top of Casing terminated at/or below land surface may require �[
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a variance in accordance with 15A NCAC 2C.0118 SIGNATURE OF CE TIFIED WELL CO R TOR DATE
i
e. YIELD(gpm): SQ METHOD,OF TEST, PRINT 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,INC 27699-1617 Phone No.[phone] ext 568. Rev.7/05

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