GW1-2022-03854_Well Construction - GW1_20220331

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RESIDENTIAL WELL CONSTRUCTION RECORD
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North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR:
f. DISINFECTION:Type HTH Amount 35
KEITH PRESNELL
g. WATER ZONES(depth):
Well Contractor(Indivi(4ual Nam21 From 122 To 125 From 225 To 226
L)L tY VVkItaH I VVELL &F'U► H L;U., INC. From To From To
Well Contractor Company Name From To From To
P. O.BOX 308
STREET ADDRESS 6.CASING: Thickness/
BOONE NC 28W7 Depth Diameter Weight Material
From d To 65 Ft. (5 1/8 .350 PVC
City or Town State Zip Code From To Ft.
( $2$ ) 264-2651 From To Ft.
Area code-Phone number
2.WELL INFORMATION: 7.GROUT: Depth Material Method
_ From 0 To 20 Ft.BEN'T_ONIT Gravity Flow_
SITE WELL ID#(itapplicable) From TO Ft. 1$BAGS
STATE WELL PERMIT#(if applicable) From To Ft.
DWQ or OTHER PERMIT#of applicable) 361182 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply From To Ft. in. in.
DATE DRILLED 3/23/2022 From To Ft. in. in.
TIME COMPLETED 02:00 AM❑ PM 91 From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
Depth Size Material
CITY: BANNERELK COUNTY ware= From To Ft.
LOT 49 MONTEAGLE OFF FOXM DR OFF MONTEA 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 58 ❑IRT
May be in degrees,
LATITUDE 3 36.192371 minutes,seconds or 58 122 GRANITE
LONGITUDE -81.$46111 in a decimal format 1" 125 REM GRANITE
Latitude/longitude source: N GPS ❑Topographic map 125 170 GRANITE
(location of well must be shown on a USGS topo map and 17n 172 01 IART7
attached to this form if not using GPS) 172 225 GRANITE
4.WELL OWNER 22S 226 ypin
OWNER'S NAME TOSRITA PRRCTtFiF("0n _225 245 GRANITE
STREET ADDRESS°%'
CORNEI MIS NC 7031
City or Town State Zip Code
( (704) )-650-5372 M
Area code-Phone number
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 245 5 G R 122- 125 25
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOJc7
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 NQAC 2C,WELL CONSTRUCTION STANDARRS,AND THAT A COPY OF THIS
O�OZH S JEEN P TO THE WE O NER.
d. TOP OF CASING IS 1 FT.Above Land Surface*
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C.0118 IGNA URE F RTIF Di LL CON OR
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e. YIELD(gpm): 30 METHOD OF TEST Air 1 i
PRINTED NAME UrP CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days.Attn:Information fMlgt., Form GW-1 a
1617 Mail Service Center-Raleigh,NC 27699-1617 Phone No.[phone] ext 5681 Rev.7/05
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