GW1-2022-08810_Well Construction - GW1_20220909

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RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
2780 ! 200144
WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount $5
KEITH PRESNELL g. WATER ZONES(depth)::'
Well Contractor(Individual Name) From n To 3?5 From 4Rn To
DEfF—Y WK1t H T VVELL &PUMP CO., iNC;. From To From To
Well Contractor Company Name From TO From To
STREET ADDRESS P. O.BOX 308 6.CASING: Thickness/
Depth Diameter Weight Material
BOORTE NC 25607 From To Ft.
City or Town State Zip Code From To Ft.
( S28 )264-2651 From To Ft.
Area code-Phone number 7.GROUT: Depth Material Method
2.WELL INFORMATION:
From To Ft.
SITE WELL ID#(if applicable) - - From - To - Ft. -
STATE WELL PERMIT#(if applicable) From To Ft.
DWQ or OTHER PERMIT#pf applicable) 172037 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water SupplyJ0 From To Ft. in. in.
DATE DRILLED 9/1112022 From To Ft. in. in.
TIME COMPLETED 03:00 AM❑ P00 From To Ft. in. in.
9.SAND/GRAVEL PACK:
3.WELL LOCATION:
Depth Size Material
CITY.DRIL-DEEPER COUNTY uTATAUGA From To Ft.
3630 OLD US 421 S OFF OFF OLD 421 OFF HVTY 421 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) May be in degrees, 0 325 EXISTING WELL
LATITUDE 3 minutes,seconds or 39 AM GRAhIITF
LONGITUDE _ _ in a decimal format AZO dgg �HAI F
Latitude/longitude source: jo GPS ❑Topographic map AcA ME GRANITE
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4.WELL OWNER
OWNER'S NAME4p,-RV TtT LffgT-W ^-
STREET ADDRESS' .AN17REW RTIMTSTFN 1€xfi t-tl_13 IIS 411 S
R('fC7N1i 14C 296(Y7 C E D n
City or Town State Zip Code
((8M )-264-8191 Inf cs�;: -�;;.-. r:?�7 Ur'
Area code-Phone number
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 605 n 5 CrUR/f 0- 325 0 5 GTPM 4R0-
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOAO
C. WATER LEVEL Below Top of Casing: 7W 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
RECO HAS BEEN PROVIDED HE WELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land Surface* ,RD
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C.0118 SIGNATURE OF CERTIFIED V7E _//Y J� Z
CL7COIqTWCW4M DATE
e. YIELD(gpm): 1 METHOD OF TEST Air ilEITW PRE-S\ICI1 I '=
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
I
Submit the original to the Division of Water Quality within 30 days.Attn:In I formation 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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