GW1-2022-02830_Well Construction - GW1_20220224

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RESIDENTIAL WELL CONSTRUCTION RECORD
�C North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 2780 210171
1.WELL CONTRACTOR:
f. DISINFECTION:Type HTH Amount 4A
KEITH PRESNELL g. WATER ZONES(depth):�
Well Contractor(Individual Name) From t7n To 1R9 From To
UEVVEY YVRiGH T WELL &PUMP CO., INC;. From 963 To )24 From To
Well Contractor Company Name From To From To
STREET ADDRESS P.O.BOAC 308 6.CASING: Thickness/
BOONE NC 28607 Depth Diameter Weight Material
From 0 To--LOQ 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_2 - Ft.BENTONI'T Graaity Flaw
SITE WELL ID#(if applicable) - `From . To Ff:1"4"BAGS
STATE WELL PERMIT#(if applicable) From To Ft.
DWO or OTHER PERMIT#(if applicable) 128631 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply From To Ft. in. in.
DATE DRILLED 1/14/2022 From To Ft. in. in.
TIME COMPLETED 03:00 AM❑ PM SI From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
Depth Size Material
CITY. BOONE COUNTY WATAUGA From To Ft.
143 CINDY RD OFF DEERF n RD OFF 321 From _To Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) From To Ft.
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
❑Slope ❑Valley ❑Flat ❑Ridge ❑Other From To Formation Description
(check appropriate box) 0 91 DIRT
May be in degrees,
LATITUDE s 36.194466 minutes,seconds or 91 170 GRANITE
LONGITUDE -81.622436 in a decimal format 170 182 01 JARTZ
Latitude/longitude source: N GPS ❑Topographic map 182 263 GEANITE
(location of well must be shown on•a USGS topo map and 263 284 QUARTZ
attached to this form if not using GPS) 284 305 GRANITE
4.WELL OWNER
OWNER'S NAMEI`KLLY MCDONAID
STREET ADDRES9I409 LAKE WALK DR.
GREENSBORO NC 27410 Q
City or Town State Zip Code
�€$ o A 2022
(( 828) )-719-7000
Area code-Phone number
5.WELL DETAILS: 11.REMARKS: IG LN
a. TOTAL DEPTH: 305 2 GPM 170- 182
b. DOES WELL REPLACE EXISTING WELL? YES❑ NV
i
c. WATER LEVEL Below Top of Casing: 80 FT. I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
(Use"+"if Above Top of Casing) 15A NCAC 2C,WELL CONSTRUCTI STANDARDS,AND THAT A COPY OF THIS 7REC D HA�ffBEENOED E WELL OWNER.
d. TOP OF CASING IS 1: FT.Above Land Surface* ��/�
* a F
Top of casing terminated at/or below land surface may require C
a variance in accordance with 15A NCAC 2C.0118 SIGNATURE OF CERTIFIED WELL CONTRA kTR DATE
e. YIELD(gpm): 10 METHOD OF TEST Air KEITH PRESNELL
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
fI
Submit the original to the Division of Water Quality within 30 days.Attn: Information)Mgt.,
(919 NC 27699-1617 Phone No.
1617 Mail Service Center-Raleigh, � e 733-7015 xt 566I . Form Rev.
, 05

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