GW1-2021-02706_Well Construction - GW1_20210811

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RESIDENTIAL WELL CONSTRUCTION RECORD
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North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# I E' 2100133
1.WELL CONTRACTOR:
f. DISINFECTION:Type HTH Amount n
KEITH PRESNELL g. WATER ZONES(depth)::
Well Contractor(Individual Name) Frq9AV4jGLLL-To From To
0AEY VVRiGHT V ELL &PUMP CO.. INC. From To From TO
Well Contractor Company Name From To From To
STREET ADDRESS P n RnX y)s 6.CASING: Thickness/
Depth Diameter Weight Material
BOONS NC 28607From_To_� Ft. ISO ��
City or Town State ZippCode From To Ft.
Area code- hone number From To Ft;
2.WELL INFORMATION: 7.GROUT: Depth Material Method
From 0 T0_20�_ Ft'.gM=M= OTSi iW jq890
SITE WELL ID#(if applicable) ---- -- From_ To- Ft:24$AGg — ----- - - - -- -
STATE WELL PERMIT#(if applicable) From To Ft
DWQ or OTHER PERMIT#(if applicable) j31Rlg &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply f7 From To Ft. in. in.
DATE DRILLED From To Ft. in. in.
TIME COMPLETED 03-M AM❑ PM)1] From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
Depth Size Material
CITY:DEEP GAP COUNTY W98MR From To Ft.
875 PINE BRANCH RD OFF PINE BRANCH OF From To Ft.
F HAR 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 25 DIRT
LATITUDE 3 — b,136t12 522 minutes,seconds or 25 40 GRANITE
LONGITUDE — — jEjX]±42 188 in a decimal format
40 300 GREEN GRANITE
Latitude/longitude source: W GPS ❑Topographic map W�o GREY GRANITE-
(location of well must be shown on a USGS topo map and ,Igpgpg 6R@€N 6Rd1IdETE
attached to this form if not using GPS)
4.WELL OWNER
OWNER'S NAMEDA�M&31MY EGMR
STREET ADDRESV5 PINE RR ANCH RD.
BOONE NC 2860
City or Town State Zip Code
(C$28) )-406-1367
Area code-Phone number �n
5.WELLDETAILS: 11.REMARKS:
a. TOTAL DEPTH: 900 0 GPM DRY HOT _
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOAQ
c. WATER LEVEL Below Top of Casing: 800 FT. I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
(Use"+"if Above Top of Casing) 15A NCAC 2C,WELL CONSTRUCTI TANDARDS,AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED T. TH WELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land Surface* '
Top of casing terminated at/or below land surface may requirea:;�
a variance in accordance with 15A NCAC 2C.0118 SIGNA U F CERTIFIED WE CONT DATE
e. YIELD(gpm): 0 METHOD OF TEST Air KEITH PRESNELL
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 568.1
1 Rev.7/05

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