GW1-2022-02822_Well Construction - GW1_20220224

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o RESIDENTIAL WELL CONSTRUCTION RECORD
�c North Carolina Department of Environment and Natural Resources-Division of Water Quality
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WELL CONTRACTOR CERTIFICATION# 2780 j 210W
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1.WELL CONTRACTOR:
KEITH PRESNELL f. DISINFECTION:Type HTH Amount 49
g. WATER ZONES(depth):,
Well Contractor(Individual Name) From 2J0 To 274 . From To
—
From S1Yhiltal-I 151VtLL PUMP CO., IIV(_. From To From To
Well Contractor Company Name From To From To
STREET ADDRESS P.0.BOX 308 6.CASING: Thickness/
$OONE NC 2MM Depth Diameter Weight Material
From 0 To 125 Ft. 61/8 .350 13VC
City or Town State Zip Code From 0 To 0 Ft.
( 828 )264-2651 From To Ft.
Area code-Phone number
2.WELL INFORMATION: 7.GROUT: Depth Material Method
From 0 To_2Q_ Ft.$ENTONPT Gram FIowa,
SITE WELL ID#(if applicable) —From- -- -To Ft 20ZAGS`
STATE WELL PERMIT#(if applicable) From To Ft.
DWQ or OTHER PERMIT#(if applicable) 185133 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply From To Ff.—in. in.
DATE DRILLED 1/29/2022 From To Ft. in. in.
TIME COMPLETED 03:00 AM❑ PM EI From To Ft. in. in.
9.SAND/GRAVEL PACK:
3.WELL LOCATION:
Depth I Size Material
CITY: $OONE COUNTY WATAUGA From To Ft.—
From--TO Ft.
OFF EAST WORD OFF S.ICN`SALE OFF LIFFOR From To Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
❑Slope ❑Valley ❑Flat ❑Ridge ❑Other From To Formation Description
(check appropriate box)
May be in degrees, ® 1.17 GIRT
LATITUDE 3 :t6 1 I I minutes,seconds or 117 172 GRq Tc
in LONGITUDE _ -81704577 a"decimal format 172 196 SHALP
Latitude/longitude source: N GPS ❑Topographic map 195 770 GRANITE
(location of well must be shown on a USGS topo map and 270 27A QUARTZ
attached to this form if not using GPS) 27d 325 ApI)TF
4.WELL OWNER
OWNER'S NAMEC RMINA &.STRVR�Jj0$E+RG
STREET ADDRESSI499 RUSS CORNKTT RD,
'ROONE . NC' 2 _
City or Town State Zip Cow—
( (OM )-964-1809
Area code-Phone number
5.WELL DETAILS: 11.REMARKS: Wow
a. TOTAL DEPTH: 325 70CI M,A 2 0
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO
c. WATER LEVEL Below Top Of Casing: RO FT. I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
(Use"+"if Above Top of Casing) 15A NCAC 2C,WELL CONSTRLj6TIqN STANDARDS,AND THAT A COPY OF THIS
HAS BEEJ1J P OVIDE TO HE WELL OWNER.
d. TOP OF CASING IS 1_ FT.Above Land Surface'
*Top of casing terminated at/or below land surface may require I Z42
a variance in accordance with 15A NCAC 2C.0118 SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): 20 METHOD OF TEST Asir
PRINTS AM O CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days.Attn: Information Mgt., Form GW-1a
1617 Mail Service Center-Raleigh,INC 27699-1617 Phone No.[phone] ext 568.: Rev.7/05
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