GW1-2022-08673_Well Construction - GW1_20220419

° STATE� I 'RECEIVED
RESIDENTIAL WELL CONSTRUCTION RECORD Apt 19 2022
- C North Carolina Department of Environment and Natural Resources-Division of Water Quality
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•� �y WELL CONTRACTOR CERTIFICATION# � ` a
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1.WELL�1 T,FM'�Q hELL f. DISINFECTION:Type i' Amount 121
�t�� ���r�� rrr�t������ g. WATER ZONES(depth):
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Well C69 W� 4LL &PUMP CO., INC:. From 370 To 395 From 670TO
From To From TO
Well Contractor Company RITBOX
308 From To From To
STREET ADDRESS PP 6.CASING: Thickness/
BOONE NC 2$607 0 Depth Defter VVhtterial
From To Ft.
8ity O WT651 State Zip Code From To Ft.
( )- From To Ft.-
Area—code-Phone number 7.GROUT Depth ertJ r PI
�pd
2.WELL INFORMATION: From To 20 BE`nn�+Ft �3�'IT Gran '
SITE WELLD#I (ii applicable) -- - - —�—---From — ___To — - Ft: —- - -------
STATE WELL PERMIT#of applicable) From To Ft.
DWQ or OTHER PERMIT#(If applicable) &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply From To Ft. in. in.
DATE DRILLED 414/2022 From To Ft. in. in.
TIME COMPLETED U3'00 AM❑ PM From To Ft. in. in.
3.WELL LOCATION: 9.SAND/GRAVEL PACK:
BLOWING ROCK CALDWELL Depth Size Material
CITY: COUNTY From To Ft.
6605 MOUNTAIN VIEW RD OFF MOUNTAIN VIEW 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 38 DIRT
_ N36*12.532 May in degrees, 38 270 GRANITE
LATITUDE 3 minutes,seconds or
LONGITUDE W081*42.395 in a decimal format 270 290 QUARTZ
Latitude/longitude source: (N GPS ❑Topographic map 290 370 GRANITE
(location of well must be shown on a USGS topo map and 370 3% ! QUARTZ
attached to this form if not using GPS) 395 510 l GRANITE
4.WELL OWNER 510 540 QUARTZ
OWNER'S NAMEESDRA.S G[TZZi " 50 705 GRANITE
STREET ADDRESS6605 MOUNTAIN VIEW RD,
BLOWING ROCK NC 28605
City or Town State Zip Code
(2( 52) ) 367-0902
Area code-Phone number
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 705 1 GPM 370-395 5 GPM 670-
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO)0
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 PROV ED TO E 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 CEFVrIFIED WEIL CONTR CR DATE v)
e. YIELD(gpm): 6 METHOD OFTEST Air 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 5 68., Rev.7/05
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