GW1-2022-08751_Well Construction - GW1_20220428

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RESIDENTIAL WELL CONSTRUCTION RECOiRD
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North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: HTH 105
KEITH PRESNELL f. DISINFECTION:Type Amount
Well CDntraclor. Inci_viduaWame�. . 9• WATER ZONES pth):
( 272 2
UtWtY V IJI-I I VVELL &PUMP CO., INC. From To From To
From To From To
Well Contractor Company Name From To From To
P.O.BOX 308
STREET ADDRESS 6.CASING: Thickness/
BOONE NC 28607 Depth Diameter Wei ht Material
From 0 To 134 Ft. 61/6 .350 PVC
City or Town State Zip Code From To Ft.
( an ) 264-2651 From To Ft.
Area code-Phone number 7.GROUT: Depth Material Method
2.WELL INFORMATION: From 0 To 20 Ft.BENTONIT &avitYF'low
--—SITE-WELL-ID-#(if applicable)—- -- - - -- —_ Erom—_ To Ft,19 BAGS
STATE WELL PERMIT#(if applicable) From To Ft.
DWQ or OTHER PERMIT#(if applicable) 5 8.SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply From To Ft. in. in.
DATE DRILLED 4/12/2022 From To Ft. in. in.
TIME COMPLETED 03:00 AM❑ PM J From To Ft. in. in.
9.SAND/GRAVEL PACK:
3.WELL LOCATION:
�ORO yS Depth Size Material
CITY: COUNTY From To Ft.
217 WARREN WAY OFF IRGHTOP DRIVE OFF BUC From _To Ft.
From To Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
IXSlope ❑Valley ❑Flat ❑Ridge ❑Other From To Formation Description
(check appropriate box) 0 126 DIRT
_ _ 36.19523N May in degrees,
LATITUDE 3 minutes,seconds or 126 230 GRANITE
LONGITUDE 81.372M in a decimal format 230 272 SHALE
Latitude/longitude source: 2 GPS ❑Topographic map 272 290 QUARTZ
(location of well must be shown on a USGS topo map and 290 310 SHALE
attached to this form if not using GPS) 310 518 GRANITE
4.WELL OWNER 518 572 SHALE
OWNER'S NAMEJEFF' Y& NIGOLE LAPORTE 572 688 GRANITE
STREET ADDRESSP BOX 41 , 688 705 VLALE
PUPMEAR NC 28665 705 B blwplIf1
City or Town State Zip Code
c( 603)�-682-3811 R 'jALn��
Area code-Phone number
5.WELL DETAILS: 11.REMARKS: � �� '1)
a. TOTAL DEPTH:
$00 0.5 GPM 272-290 ,,,.t„'� IR:0CS��'�a Icl�(I
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOX]
c. WATER LEVEL Below Top of Casing: 300 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 TOTM WELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land Surface* ` •r1
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C.0118 SIGNATUREOF C RTI IED WML CONTRACTOR o DATE
e. YIELD(gpm): 0.5 METHOD OF TEST Air KEITH PRESNELL
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
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Submit the original to the Division of Water Quality within 30 days.Attn:Information Mgt., Form GW-1 a
1617 Mail Service Center-Raleigh,INC 27699-1617 Phone No.[phone] ext 568 Rev.7/05

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