GW1-2022-08692_Well Construction - GW1_20220428

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RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 2780 210219
1.WELL CONTRACTOR:
f. DISINFECTION:Type 'emu Amount 27
KEITH PRESNEI I g. WATER ZONES(depth):'
Well Contractor(Individual Name)
From log To lig From 16 T0494
UEVVtY YYFit(.aFi I V1LL tf F'L11VIf=' i U.. IIVC . From To From To
Well Contractor Company Name
From To From To
STREET ADDRESS _D,Q,ROX 302 6.CASING: Thickness/
Depth Diameter Weight Material
BOONE NC 28607 From_0 To--,6(�- Ft. 6 1/8 .35() PVC
City or Town State Zip Code From To Ft.
O- From To Ft.
Area code- one number
2.WELL INFORMATION: 7.GROUT: Depth Material Method
From 0To a0 Ft.BE, = Gmi ne-p
--
SITE-V11ECL.ID#(if applioable}- -From----
STATE WELL PERMIT#(if applicable) From To Ft.
DWQ or OTHER PERMIT#(if applicable) 8.SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply From To Ft. in. in.
DATE DRILLED From To Ft. in. in.
TIME COMPLETED�7: AM❑ PM fI7 From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
Depth Size Material
CITY: BLOMMIG ROCK COUNTY rATT5WRT1. From To Ft.
From To Ft.
4937 ROCKY IONOB IY ADOWS OFF COCKY KNOB 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)
May be in degrees, a 56 DIRT
LATITUDE 3 361108{0{ minutes,seconds or copy 1 GR#A!TC
LONGITUDE 6i t�oW- in a decimal format 6 ` ,
ANiTE
Latitude/longitude source: R GPS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
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GRMTIE
4.WELL OWNER 1168 1173
OWNER'S NAME &yR&LOW qrcqqL 17a 205 GRANITE
STREET ADDRESSm,)ROv 3349,
NG Pr
oy�,%ROGK State Zip —
( (M )-848-15055 APR 2 9 2027
Area code-Phone number
5.WELL DETAILS: 11.REMARKS: ? i
a. TOTAL DEPTH:. 205 4 GM& 109- 114 -2 GW5, Q4i J,10 SSii G UNU
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO
c. WATER LEVEL Below Top of Casing:�n FT. I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
(Use"t"if Above Top of Casing) 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
RECORD HAS BE N P OVID O THE WELL OWNER.
d. TOP OF CASING IS I FT.Above Land Surface*
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C.0118 SIGNAT E OF TIFIED CON OR I DATE
e. YIELD(gpm): 6 METHOD OF TEST
PRIN AM 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 5681 Rev.7/05

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