GW1-2022-06660_Well Construction - GW1_20220708

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.: . RESIDENTIAL WELL CONSTRUCTION RECORD
�C North Carolina Department of Environment and Natural Resources-Division of (Water Quality
WELL CONTRACTOR CERTIFICATION# 2780 I
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 0
KEITH PRESNELL
g. WATER ZONES(depth):
Well Contractor(Individual Name Fro�Y HOLE To From TO
U EVVEY VAiGH I WELL &HFUMP CO., INC.
From To From To
Well Contractor Company Name From To From To
STREET ADDRESS P.O.BOX 308 6.CASING: Thickness/
BOONE NC 22607 Depth Diameter Weight Material
From 0 To 38 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:BENTONIT__ raylty Flow-
SITE WELL ID#(if applicable) From To Ft.20 BAGS
STATE WELL PERMIT#(if applicable) From To Ft.
DWQ or OTHER PERMIT#(if applicable) 367373 8.SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply From To Ft. in. in.
DATE DRILLED 6/23/2022 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: DRY HOLE COUNTY Watsaua From To Ft. _
OFF ANDY HICKS RD OFT'WORLEY OFF OUVER H "�� �,,„e
From _TO Ft. r f+
From TO Ft. � 1 t L„ /.
(Street Name,Numbers,Communit)4 Subdivision,Lot No.,Parcel,Zip Code) JUL O
S 2022
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
❑Slope ❑Valley ❑Flat ❑Ridge ❑Other From To Fri ta41 I e�c°ri�ioh '3 Ur
(check appropriate box) 0 29 DIRT R✓�'�/ -%7G
36.21286N Maybe in degrees, 186 GRANITE
LATITUDE 3 minutes,seconds or
LONGITUDE 81.83774W in a decimal format 186 192 SHALE
Latitude/longitude source: I GPS ❑Topographic map 192 360 GRANITE
(location of well must be shown on a USGS topo map and 360 389 SHALE
attached to this form if not using GPS) 389 500 GRANITE
4.WELL OWNER
OWNER'S NAMEDUSTIN&=SAY MNCKNEY
%JILL'RIGHT, 585 FIELDSTREAM DR
STREET ADDRESS
BOONE NC 28607
City or Town State Zip Code
(( 843) )- 2%-5438
Area code-Phone number
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 500 0 GPM DRY HOLE
b. DOES WELL REPLACE EXISTING WELL? YES❑ N07ILI
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c. WATER LEVEL Below Top of Casing: Soo 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 MOVLDED TOATItiWELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land Surface* U^/ 1 Ul
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C.0118 SIGNATURE OF CERTIFIED WELL CONT TO DAT
0 Air KEITH PRESNE'LL
e. YIELD(gpm): METHOD OF TEST
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,INC 27699-1617 Phone No.[phone] ext 568. Rev.7/05
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