GW1-2022-06393_Well Construction - GW1_20220603

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RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
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WELL CONTRACTOR CERTIFICATION# 2780 I 210048
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 73
KEITH PRESNELL
g. WATER ZONES(depth):
Well Contractor(Individual Name) 365
DEWE'Y VVRIGHT WELL &PUMP CO., INC. From To From To
From To From To
Well Contractor Company Name From To From To
STREET ADDRESS p O.BOX 30$ 6.CASING: Thickness/
BOONE NC 28M Depth Diameter Weight Material
From 0 To 178 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.BENTONTT Gravity Flow
--SITE WELL iD#pf applicable) From`--Ta— -
STATE WELL PERMIT#(a applicable) From To Ft.
DWQ or OTHER PERMIT#(a applicable) 306W5 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply From To Ft. in. in.
DATE DRILLED 6/1/2022 From To Ft. in. in.
TIME COMPLETED 03:00 AM❑ PM ] From To Ft. in, in.
9.SAND/GRAVEL PACK:
3.WELL LOCATION:
Depth Size Material
CITY: BOONE COUNTY W=911e From To Ft.
OFF POPLAR GROVE RD S OFF HWY 105 OFF RWY 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) 0 169 DIRT
N36*26 077 May be in degrees, 169 286 GRANITE
LATITUDE 3 minutes,seconds or
LONGITUDE
W081*39.765 in a decimal format 286 294 SHALE
Latitude/longitude source: Q§GPS ❑Topographic map 294 332 GRANITE
(location of well must be shown on a USGS topo map and 332 338 GRANITE/OUARTZ
attached to this form if not using GPS) 3W 368 GRANITE
4.WELL OWNER 3W 375 LIMESTONE
OWNER'S NAMERO$ERT D COOK 375 425 � ��_
STREET ADDREss1467 POPLAR GROVE RD S,
BOONS NC 286M a N n 3 202?
City or Town State Zip Code
(( 8m) )-964-5785 „ , .;ON
Area code-Phone number
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5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 425 1 GPM 365-
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO)U
c. WATER LEVEL Below Top of Casing: 60 FT. I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
(Use"+"if Above Top of Casing) 15A NCAC 2C,WELL CONSTRUCT N STANDARDS,AND THAT A COPY OF THIS
REC RD HAS BEEN PROVIDED HE WELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land Surface*
Top of casing terminated at/or below land surface may require r p(
a variance in accordance with 15A NCAC 2C.0118 SIGNATURE OF(TERTIFf_1E07VtLL CN,4 I KAG I OR DATE `
e. YIELD(gpm): 1 METHOD OF TEST Au' 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:Informatio!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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