GW1-2022-03041_Well Construction - GW1_20220228

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- RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
2780 210179 `WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: HTH
KEITH PRESNELL f. DISINFECTION:Type Amount 70 -- --
g. WATER ZONES(depth):'
Well Contractor(Individual Name) From 189 To 196 From To
DEWEY YVRiGH T 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/
BOONE NC 2$607 Depth Diameter Weight Material
From 0 To 40 Ft. 6I18 .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 F,t.BENTONTT Gravity Flow
— SITE-WELL-ID-#(if-apprcable) ----- -- — From— -—To - r Ft:-2A BAGS- .
STATE WELL PERMIT#(if applicable) From To Ft.
DWQ or OTHER PERMIT#(d applicable) 356490 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply From To Ft. in. in.
DATE DRILLED 2/1712022 From To Ft. in. in.
TIME COMPLETED 03:00 AM❑ PMZI From To Ft. in. in.
3.WELL LOCATION: 9.SAND/GRAVEL PACK:
CITY:
PINEY CPJMK COUNTYAT I GA From _To Ft.Y Depth Size Material
LOT#27 OFF SOUTH FORK CHQR.CH RD OFF 1UNG From _To Ft..
From To Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) F EB
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG PfO 1111N
El
❑Valley El Flat ❑Ridge El Other From To rmation
(check appropriate box) 0 31 DIRT
May be in degrees,
LATITUDE 3 36.565184 minutes,seconds or 31 189 GRANITE
LONGITUDE -81.255298 in a decimal format 189 196 QUARTZ
Latitude/longitude source: ®GPS ❑Topographic map 196 270 GRANITE
(location of well must be shown on a USGS topo map and 270 300 SHALE
attached to this form if not using GPS) 0 365 GRANITE
4.WELL O �n 365 380 SHALE
OWN 'S NAMEVERNIE DOVE 3W 425 GRANITE
STRE ADDRESSl675 BLOWING ROCK
BaM
NG 28607
City wn State ?Zip Code
(9( 19) )_264-8832
Area code-Phone number
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 425 2 GPM 189- 196
b. DOES WELL REPLACE EXISTING WELL? YES❑ NC)0
80
c. WATER LEVEL Below Top of Casing: FT. I DO HEREBY CERTIFY THAT THIS WELL AS CONSTRUCTED IN ACCORDANCE WITH
(Use"+"if Above Top of Casing) 15A NCAC 2C,WELL CONSTRUCTIO NDARDS,AND THAT A COPY OF THIS
IDED T H ELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land Surface' M
'Top of casing terminated at/or below land surface may require mm
a variance in accordance with 15A NCAC 2C.0118 SIGNATURE OF CERTIFIED WELL CONTRAC R DATE
e. YIELD(gpm): 2 METHOD OF TEST Air KEITH PRESNELL
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
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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 668.
8. Rev.7/05
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