GW1-2022-04871_Well Construction - GW1_20220520

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RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
. ,. 2760 21�►3t5?.
WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: H T H
KEITH PRESNELL f. DISINFECTION:Type Amount
g. WATER ZONES(depth):
Well C.ontraclor.(Individu Name.. . 250 231 3�R 3:;g
U�_-Vv`_-Y V`&lItaH 1 Vi ALL 6:{="L1t�P C0.. (NC'. From To From To
From To From To
Well Contractor Company Name From To From To
R O.BOX,30s
STREET ADDRESS 6.CASING: Thickness/
Dr-001gE I-C, 2260 Depth Diameter Weight Material
From 0 To 52 Ft. 6 1IS J�;Q 1Tvr,
City or Town State Zip Code From To Ft.
$2 8 2i�-?�i31
( )- From To Ft.
Area code-Phone number 7.GROUT Depth Material Method
2.WELL INFORMATION:
From :. To ., Ft.r
SITE WELL ID#(if applicable) From To Ft.RF.T,I11 t 1I11'I — - - "-
STATE WELL PERMIT#(if applicable) From To Ft.
DWQ or OTHER PERMIT#(if applicable) 131726 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply Q From To Ft. in. in.
DATE DRILLED 511212•022 From To Ft. in. in.
TIME COMPLETED 03:00 AM❑ PM® From To R. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
Depth Size Material
CITY: B0U1`TF, COUNTY w a_-a From To Ft.
149 S1,TOWY D OE R-D OZ IT WL.L E'a NAY OT-17 D OF From To F=t.
(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)
May be in degrees, " Ae M I r=.T
LATITUDE 3 ej 7.�i7.P;7.0 1 minutes,seconds or .1r, fir, r_-_rM.6u,_a 6nll
LONGITUDE {1 �1� }: ; in a decimal format
- rYIl_PT-Jr^RFtnr^G
Latitude/longitude source: 14GPS ❑Topographic map ?51 Ks _ rzp6_(ZP 6i'l ITF
(location of well must be shown on a USGS topo map and 3 g r,116P T 7fCP=k4,11=
attached to this form if not using GPS) = 911 1 I1=C- anIITE
4.WELL OWNER
OWNER'S NAME TP.1R T 1 tR C;'R AT)V
STREET ADDRESS',A,in-LITVT i1A V i-1C)TT Zq 4-7 Rnf'k J:'1'RF j v­ s^�
RC7,^?TH-. 'NTH `SFdS7 --
City or Town State Zip Code MAY
C3( M 1-773-7179 _ >
Area code-Phone number _
5.WELLDETAILS: 11.REMARKS:
a. TOTAL DEPTH: 405 1 rs?3 E 25 nc 0_ , )1
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOU
c. WATER LEVEL Below Top of Casing: ;Ol FT. I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
(Use"+"if Above Top of Casing) 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
RECORD HAS BEEN PFPVIDED PIE WELL OWNER.
d. TOP OF CASING IS I F E Above Land Surface`
Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C.0118 SIGNATURE OF CERTIFIED WELL CONTRA OR DATE
e. YIELD(gpm): 4 METHOD OF TEST i); 1-s�1 e� oT' R" I
PRINTEI�NAME 01-P _R5OI7 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, INC 27699-1617 Phone No.[phone] ext 568. Rev.7/05

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