GW1-2021-02746_Well Construction - GW1_20211130

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RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
2780 ! 210220
WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 38
KEITH PRESNELL
g. WATER ZONES(depth):
Well Eo trpglpr I(ndLyidual�lam�, , From 120 To 125 From To
DEVVEY i RiGH I WELL &PUMP CO.. INC.
From To From To
Well Contractor Company Name From To From To
STREET ADDRESS P.O.BOX 30$ 6.CASING: Thickness/
BOONS NC 28607 Depth Diameter Weight Material
From 0 To (50 Ft. 6118 .350 PVC
City or Town State Zip Code From To Ft.
( 828 )264-2651 From To Ft.
Area code-Phone number
2.WELL INFORMATION: 7.GROUT: Depth Material Method
From 0 To 20 Ft.BENTOMT Gravity Flow
SITE WELL ID#rf a licable — _ __ Fiorri--- . TO— Ft 29­BAGS`_—_
STATE WELL PERMIT#(d applicable) 369724 From To Ft.
DWQ or OTHER PERMIT#(if applicable) &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Ap licable Box): Residential Water Supply From To Ft. in. in.
DATE DRILLED �1/1212021 From To Ft. in. in.
TIME COMPLETED AM❑ PA From To Ft. in. in.
9.SAND/GRAVEL PACK:
3.WELL LOCATION:
Depth Size Material
CITY: BOONE COUNTY w188gl1a From To Ft.
333 GEORGE W LSON RD OFF HODGES GAP OFF H 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 52 DIRT
May be in degrees,
LATITUDE 3 36.22408 minutes,seconds or 52 93 GRANITE
LONGITUDE 81.71362- in a decimal format 93 95 QUARTZ
Latitude/longitude source: 09 GPS ❑Topographic map 95 120 GRANITE
(location of well must be shown on a USGS topo map and 120 125 l QUARTZISHALE
attached to this form if not using GPS) 125 188 GRANITE
4.WELL OWNER 188 193 SHALE
OWNER'S NAME="Y&MATTI EW FIARMON 193 200 GRANITE
STREET.ADDRESSY-PIEDMONT HOMES;,_U I_E FLEMING,DR
MORGANTON NC 28655 >, ,a .q� -.
City or Town State Zip Code„'
(( 8M )_391-1485
Area code-Phone number
5.WELLDETAILS: 11.REMARKS: j
a. TOTAL DEPTH: 200 10 GPM 124-125 V
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO)7
c. WATER LEVEL Below Top of Casing: 20 FT I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
(Use"+"if Above Top of Casing) 15A NCAC 2C,WELL ONSTRU ON STANDARDS,AND T T A COPY OF THIS
RE OR HASB N OVID T THE'WELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land Surface` 1 f, 1
*Top of casing terminated at/or below land surface may require liolo a variance in accordance with 15A NCAC 2C.0118 SIG TU F ClEATIFIETWELL CONTRACTOR DATE
e. YIELD(gpm): 10 METHOD OF TEST Air KEITH PRESNELL
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

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