GW1-2022-08640_Well Construction - GW1_20220419

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RESIDENTIAL WELL CONSTRUCTION RECORD
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North Carolina Department of Environment and Natural Resources-Division of Water Quality
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WELL CONTRACTOR CERTIFICATION# 2780 220025
1.WELL CONTRACTOR: HTH 109
KEITH PRESNELL f. DISINFECTION:Type Amount
g. WATER ZONES(depth):
Well Coo r r(tnclLv��u l fte)WELL PUMP CO., INC. From 530 To 560 From 560To 605
D WR T From To From To
Well Contractor Company Name From To From To
P.0.BOX 308
STREET ADDRESS 6.CASING: Thickness/
BOONE NC 28607 Depth Diameter Wei ht Material
From 0 TO 108 Ft. 61/8 .35t� PVC
City or Town State From To Ft.
828 264-2651
( )- From To Ft.
Area code-Phone number 9 2022
APR 1 7.GROUT: Depth L Material Method
2.WELL INFORMATION: From 0 To 24 t BENTONIT GravitYFlcw
SITE WELL ID#(ifapplicable) �.,..nt U From TO Ft.54BAGS
STATE WELL PERMIT#(if applicable) From To Ft.
DWQ or OTHER PERMIT#(if applicable) 366634 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply C From To Ft. in. in.
DATE DRILLED 4/7/2022 From To Ft. in. in.
TIME COMPLETED AM❑ PM From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
WEST.>EFF'ERSON ASHE Depth Size Material
CITY: COUNTY From —TO—;Ft.—
OFF NC HtATY 16S OFF HWY 163 OFF MLEWMD RD 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 91 DIRT
36.32458N May in degrees, 91 230 GRANITE
LATITUDE 3 minutes,seconds or
LONGITUDE --8T.-S' 1W in a decimal format 230 272 SHALE
Latitude/longitude source: &PS ❑Topographic map 272 422 GRANITE
(location of well must be shown on a USGS topo map and 422 488 SHALE
attached to this form if not using GPS) 488 495 RED GRANITE
4.WELL OWNER 495 530 GRANITE
OWNER'S NAME =BROADWAY GROUP/DOLLAR GEN 5W 560 SHALE
STREET ADDRESSM WUTSIDE SQUARE. 560 605 GRANITE
HUNTSVn S F AL 35801
City or Town State Zip Code
(2( 256) 801-5146
Area code-Phone number
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 605 6.5 GPM 530-560 4.5 GPM 560-605
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOXI
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c. WATER LEVEL Below Top of Casing: $© 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
REC D S BEEN PR VID TOIT ELL OWNER.
d. TOP OF CASING IS 1 FT Above Land Surface' I R
Top of casing terminated at/or below land surface.may require O)'
a variance in accordance with 15A NCAC 2C.0118 SIGNAT E CERTI WE T OR ATE
e. YIELD(gpm): 11 METHOD OF TEST Au KEITH PRESNELL
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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