GW1-2022-06417_Well Construction - GW1_20220706

MC STATE o�
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
2 SO
WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: f. DISINFECTION:Type " H Amount 73
i�EITH PRESNELL
g. WATER ZONES(depth):
Well Contractor(Individual Name) From 236 To i65' From To
❑E1,°dCY 1,`LFIOHT!HELL PUMP CO., INC.
From To From To
Well Contractor Company Name From To From To
P.Cl.t:t���3tj.',
STREET ADDRESS 6.CASING: Thickness/
F100 TE ITry 23607 Depth Diameter Weight Material
From 0 To 12.0 Ft. �it_ 3 5 15 u'v t_'
City or Town State Zip Code From To Ft.
From To Ft.
Area code-Phone number
7.GROUT: Depth Material Method
2.WELLINFORMATION: 0 20_ 1`"k�T17-(] TT'1� ri�git*�FiLsAj
- - — ---- - -- — ----From- To- Ft:=' -
SITE WELL ID#(if applicable) From To Ft.19`AC-L
STATE WELL PERMIT#(if applicable) From To Ft.
DWQ or OTHER PERMIT#(if applicable) 1 }' &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply I From To Ft. in. in.
DATE DRILLED 'Pf `lyz' From To Ft. in. in.
TIME COMPLETED tId' AM❑ PM❑ From To Ft. in. in.
&WELL LOCATION: 9.SAND/GRAVEL PACK:
Tt;ESS, EFFE2q�J1.T -L_11HE Depth Size Material
CITY: COUNTY From To Ft.
LOT•i 77TT E TW OC) 1 kCIR `S OFF Vk,1 T1T_rEVT r,P;' t]_G`k From _To Ft.
(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) 0 111 DI,a,T
May be in degrees,
LATITUDE 3 36.361335 minutes,seconds or 111 2365 GRANITE
LONGITUDE -eL50805,? in a decimal format 2.Y, 263 GFANITJGU:RTZ
Latitude/longitude source: 12I GPS ❑Topographic map ztb_; Y-30 GR IN I T E
(location of well must be shown on a USGS topo map and 330 343 -SHALE
attached to this form if not using GPS) '3 425. G RAN ITE
izr j ja 1."e'v
4.WELL OWNER ` t..-
OWNER'S NAMEAJTAI?F_ u�4-tTE�L
STREET ADDRESS/.TALLTOii BUILDERS, 401 COX P-r JL t3 2Q2Z
J_R_ aSO11T ITC 2'SY)4
City or Town State Zip Code n`r� ,ti;� =;I .'r 'c. ".";y U
Area code-Phone number
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 4"5 i` PIA 2_26-269
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO❑
c. WATER LEVEL Below Top of Casing: 0 FT. I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
(Use"+"if Above Top of Casing) 15A NCAC 2C,WELL CONSTRUCTI 1 STANDARDS,AND THAT A COPY OF THIS
RE_QgFIDHASBE P VIDED T E WELL OWNER. Z
d. TOP OF CASING IS 1 FT.Above Land Surface` u
`Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C.0118 SIGNATURE OF CERTIFIED WELL CONTRAC OR DATE
e. YIELD(gpm): j METHOD OF TEST Air !;EI I H PP'ESNEI I.
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 568. Rev.7/05

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