GW1-2022-06416_Well Construction - GW1_20220706

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RESIDENTIAL WELL CONSTRUCTION RE
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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 H l H Amount 45
KEITH PRES EI-L
g. WATER ZONES(depth):
Well Contractor(Individual Name) 12+ l2g 290 29l
L �,• i f..- From To From To
From To From To
Well Contractor Company Name From To From To
STREET ADDRESS
P.O.-10J`JtJ, 6.CASING: Thickness/
001ice _NI C d t- := Depth Diameter Weight Material
t� - -- -
From =' To `? Ft. i'!i{ �J- 'tr'•'
City or Town State Zip Code From To Ft.
From To Ft.
Area code-Phone number 7.GROUT.
Depth
-- -- -- - -— - -- - - - De th 1Mt9{at eGrtia17l Method
-02.WELL INFORMATION: 0 To =t:From- =2lt','=10t;
SITE WELL ID#(if applicable) From To Ft.
STATE WELL PERMIT#(if applicable) From To Ft.
DWQ or OTHER PERMIT#(It applicable) S.SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply From To Ft. in. in.
t1/_1202u
DATE DRILLED From To Ft. in. in.
TIME COMPLETED �ri:00 AM❑ PM© From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
Depth Size Material
CITY: C-1F
"TTsTON COUNTY A_QE:E
From To Ft.
OFF PD E IAOTJI:7__�T]D COT ER.uSY FORD Ot 1-_q 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 72, DIRT
May be in degrees, _r — __
LATITUDE 3 minutes,seconds or `� 1�'=' t_FP.i'lITE
LONGITUDE in a decimal formal 1_= 128 QUARTZ
Latitude/longitude source: (�GPS ❑Topographic map `t' 110 t'R^j}l)
(location of well must be shown on a USGS topo map and 2'1�I `225 SHALE
attached to this form if not using GPS) 22= 290 Gh.'-RITE
4.WELL OWNER 220 291 V AID
OWNER'S NAME
J�^ ��tlCiid M_ 3u5� t3F;?s�1TE
tt I$ POUNDrs'OUT IRD,
STREET ADDRESS``
=TON NIC G Ml5
City or Town State Zip Code
Area code-Phone numberRZ
m"
5.WELLDETAILS: 11.REMARKS: JUL ,s
SUS 2 fap:r rj 1�. _ 12 4•f`LTt�.rT 29'�.-2.91
a. TOTAL DEPTH: �
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO i7
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 CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
RECORD HA$BEEN P VID O THE WELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land Surface" 1
Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C.0118 SIGNAT RE OF TIFIED LL CON A R DATE
e. YIELD(gpm): METHOD OF TEST F'`I T H 'rRF`NIELL
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
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 563. Rev.7/05

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