GW1-2022-03040_Well Construction - GW1_20220228

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RESIDENTIAL WELL CONSTRUCTION RECORD
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North Carolina Department of Environment and Natural Resources-Division of water Quality
2780 220006
WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: HTH 88
KEITH PRESNELL f. DISINFECTION:Type I Amount
g. WATER ZONES depth): f
Well Contractor IDdividual-Name). . From 51 To 196 From To
ULVVtY IUH I WLLL &h'tJMt (;U.. INU.
From To From To
Well Contractor Company Name P.O.BOX 308 From To From To
STREET ADDRESS 6.CASING: Thickness/
BOONE NC 28W7 Depth Diameter Weight Material
From 0 TO 60 Ft: 61/8 •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'
BENTONIT Gravity Flow
SITE WELL ID#(if applicable) From To Ft 21 BAGS
STATE WELL PERMIT#(if applicable) From To Ft
DWQ or OTHER PERMIT#(•n applicable) &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply From To Ft: in. in.
DATE DRILLED 1V21/2022 y, From To Ft`. in. in.
TIME COMPLETED AM❑ PM LJ' From To Ft. in. in.
3.WELL LOCATION: 9.SAND/GRAVEL PACK:
DEEP GAP WATAUGA Depth Size Material
CITY: COUNTY From TO Ft.
#228 ROUM RIDGE RD OFF 421 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 FormationiC VE
(check appropriate box) 0 51 i DIRT S
_ 36.2455?9 May be in degrees,
LATITUDE 3 minutes,seconds or 51 196 GRANITE Gf=R 9 8 2
LONGITUDE -81.522542 in a decimal format 196 238 SHALE
Latitude/longitude source: A GPS. ❑Topographic map 238 291 GRANITE 0n Procaosm0 U
(location of well must be shown on a USGS topo map and 291 300 QUARTZ
attached to this form if not using GPS) 300 3 SHALE
4.WELL OWNER 31% 410 GRANITE
OWNER'S NAMEPAM SOAVE 410 460 - SHALE
STREET ADDRESS BOX 461, 460 505 GRANITE
DEEP GAF NC 2861$
City or Town State Zip Code
(8( 50) )_855-M21
Area code-Phone number
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 505 1 GPM 51 - 196
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOM
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 CONSTRUCTLQA STANDARDS,AND THAT A COPY OF THIS
REC D AS BEE P VIDED T T WELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land Surface* , �„ ��65.6
*Top of casing terminated at/or below land surface may require /
a variance in accordance with 15A NCAC 2C.0118 SIGNATURE OF CERTIFIEDf i-L CONTRACTOR DATE
e. YIELD(gpm): 1 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: InformationjMgt., Form GW-1a
1617 Mail Service Center-Raleigh, NC 27699-1617 Phone No.[phone] ext 568. Rev.7/05
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