GW1-2022-07111_Well Construction - GW1_20220801

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RESIDENTIAL WELL CONSTRUCTION REC RD
- C North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION#
,
1.WELL CONTRACTOR: If. DISINFECTION:Type HTH Amount 126
KEITH PREENELL
g. WATER ZONES(depth):
Well Q-cotraflor.(IpdividtiaLNa(nie) From 180 To 230 From 710 T 712
ULVVEY WHIt3H I VvtLL &HUMP CO., NC.:.
From To From TO
Well Contractor Company Name From To From TO
STREET ADDRESS P.O.BOX 30$ 6.CASING: Thickness/
BOONE NC 28607 Depth Diameter Wei ht Material
From 0 To 78 Ft. 6118 .350- FVC
City or Town State Zip Code From To Ft.
( 828 )264-2651 From To Ft.
Area code-Phone number 7.GROUT: Depth aterisl Method
2.WELL INFORMATION: 0 20 BENTONrr GravltyF`loeir-
- - -- - ------ ---From- - To -- Ft-- -- -
SITE WELL ID#(if applicable) From To Ft.
STATE WELL PERMIT#(if applicable) From To Ft.
DWO or OTHER PERMIT#(if applicable) 31 &SCREEN: Depth Diameter Slot Size Material
WELL USE Check A Ica I ox: Residential Water Su I From To Ft. in. in.
DATE DRILLED ��41�Z82 ) }}��pp y From To Ft. in. in.
TIME COMPLETED 03.00 AM❑ PA From To Ft. in. in.
9.SAND/GRAVEL PACK:
3.WELL LOCATION: Depth Size i �,IM di I VED
1r'IIaA.S Wat=a
CITY: COUNTY From--TO--Ft.
OFF PALL ERS PEAK OFF CHARzJE TFHOIMON RD From _To Ft. AUG0 12022
From To ' Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) 9
DVII018?G
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
❑Slope ❑Valley ❑Flat ❑Ridge ❑Other From To Formation Description
(check)(ppropriate box) 0 69 niRT
May be in degrees,
LATITUDE 3 minutes,seconds or 59 180 GRANITE
LONGITUDE in a decimal format 180 �30 SHAIF
Latitudeflongitude source: W GPS ❑Topographic map ')30 26 1 RED GRANITE
(location of well must be shown on a USGS topo map and 260 3W rp enll
attached to this form if not using GPS) 4 At c
4.WELL OWNER9gEI � }11TF
OWNER'S NAME 14Ol'iS n rRR=ZE T rpjQLTF TAT C +�, RED�•pnt AtTF
STREET ADDRES DA111 MORRIC 207 NEW M�RKFT C TiiJ'1` aft 71n GRANITE
�10 li2 unit?
FIr own State Zip o e 712 7410 12R.A-DIITE
Area code-Phone number
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 740 0 5 C*MA 380-230 14 5 CTMA 310-'712
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOAL)
c. WATER LEVEL Below Top of Casing: 100 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 PROVIDED TO WELL OWNER.
d. TOP OF CASING IS 1 FT.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 CE IED WELL CO R DATE
e. YIELD(gpm): 15 METHOD OF TEST Air KFITH PRF- IFI 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-1a
1617 Mail Service Center- Raleigh, INC 27699-1617 Phone No.[phone] ext�568. Rev.7/05

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