GW1-2022-03850_Well Construction - GW1_20220331

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.; RESIDENTIAL WELL CONSTRUCTION RECdRb
�c North Carolina Department of Environment and Natural Resources-Division of Water Quality
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WELL CONTRACTOR CERTIFICATION# 2780 i 210215
1.WELL CONTRACTOR: HTH 70
KEITH PRESNELL f. DISINFECTION:Type Amount
Well�Q r r.Q.� g• WATER2j?NESldepth): 3>I7 390
LAI 1rYrGll +I LL &PUMP CO., INC. From uu To 11 44 From To
From To From To
Well Contractor Company Name From To From TO
STREET ADDRESS _A 0.ROX 309 6.CASING: Thickness/
BOONE NC 28607 Depth Diameter Weight Material
From 0 To 45 Ft. 61/8 .350 we
City or Town State Zip Code From To Ft.
( 82$ )-264-2651 From To Ft.
Area code-Phone number
2.WELL INFORMATION: 7.GROUT: Depth Material Method
FromQTo 20 Ff.B=Qb= Gt ity-m m
— " . --- __ -- - ---- -- —_ ---- - ___
SITE WELL )#(if applicable) From TO Ft.72 RAC'Pq
STATE WELL PERMIT#(if applicable) From To Ft.
DWQ or OTHER PERMIT#(if applicable) 10717 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply Q From To Ft. in. in.
DATE DRILLED 1/2112022 From To Ft. in. in.
TIME COMPLETED 03:00 AM❑ PM W From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
Depth Size Material
CITY: BAN14MELK COUNTY AVERY From To Ft.
LOT 23/24 FOX MEADOW FARMS OFF FOX MEADO 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 36 DIRT
May be in degrees,
LATITUDE 3 36.181739 minutes,seconds or 36 210 GRANITE
LONGITUDE -$1.$6297$ in a decimal format 210 214 QUARTZ
Latitude/longitude source: QGPS ❑Topographic map 12,d, 280 GRANITE
(location of well must be shown on a USGS topo map and �n 300 RED GRANITE
attached to this form if not using GPS) 3W 37 GRANITE
4.WELLOWNER 387 30 QUARTZ
OWNER'S NAMEWC HAFT_t$GINA =17E DE _ 90 425 ' fZRANITF
STREET ADDRESSBOX 4074 1054 FOX MRADQVI RD
City or Town State Zip Code ZOE
467-7919 NA AR
Area code-Phone number
5.WELL DETAILS: 11.REMARKS: `
a. TOTAL DEPTH: 425 4 GPM 210-214 2 GPM'387=390
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOXI
c. WATER LEVEL Below Top of Casing: 8o FT. I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
(Use"+"if Above Top of Casing) 15A NCAC 2C,WELL CONSTRUCTION STAND DS,AND THAT A COPY OF THIS
R O D AS B N RO IDED THE NER.
d. TOP OF CASING IS 1 FT.Above Land Surface*
*Top of casing terminated at/or below land surface may require i
a variance in accordance with 15A NCAC 2C.0118 SIGNATURE OF CE TIFI LL C RAC AT
e. YIELD(gpm): 6 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:Information Mgt., Form GW-1 a
1617 Mail Service Center- Raleigh,NC 27699-1617 Phone No.[phone] ext 5681 Rev.7/05

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