GW1-2022-09129_Well Construction - GW1_20220930

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RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 2780 G 210190
1.WELL CONTRACTOR:
I.EiTH PRESNELL f. DISINFECTION:Type HTH Amount 66
g. WATER ZONES(depth):
Well Contractor(Individual Name) From 235 To 160 From To
DEV%F-Y VAiGH i'Vv1=LL &h'I.1MP CO., INC:. From To From To
Well Contractor Company Name From To From To
STREET ADDRESS P.O.BOX 308 6.CASING: Thickness/
BOONE 14C 22607 Depth Diameter Weight Material
From0 To--L(XL Ft. d 1/9 350 TYV(7
City or Town State Zip Code From To Ft.
( 828 )-2b4-2651 From To Ft.
Area code-Phone number
7.GROUT: Depth Material Method
2.WELL INFORMATION:
-From_QTo 20 IttBENT©Nt'P -rff-mitviziow
SITE WELL ID#(if applicable) From To Ft.20BAGS
STATE WELL PERMIT#(if applicable) From To Ft.
DWQ or OTHER PERMIT#(if applicable) 147453 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply$) From To Ft. in. in.
DATE DRILLED 9/112022 From To Ft. in. in.
TIME COMPLETED 03:00 AM❑ PM)) From To Ft. in. in.
9.SAND/GRAVEL PACK:
3.WELL LOCATION:
Depth Size Material
CITY.FLZ=OOD COUNTY ASHE From To Ft.
GREEN MEADOWS DR OFF BROWN RD OFF RA= 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 Bo DIRT
LATITUDE 3 minutes,seconds or as 142 �
LONGITUDE in a decimal format �42 156 81
Latitude/longitude source: W GPS ❑Topographic map 156 160 n�i 8F7T7
(location of well must be shown on a USGS topo map and tFn 220 GREEN GRANITE
-attached to this form if not using GPS) 9,)n W ' GRANITE
4.WELL OWNER 3sn 'AS QUART?
OWNER'S NAMETB&O= LEE 69 Arun GRANITE
—` STREET ADDRESS/o-
FLEErWOOD NC 28626
City or Town State Zip Code
V d
(=X) )-964-1289 s
Area code-Phone number S E P 3 2022
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 400 2 GRA 156- 160 In"'r-in c'n ?ra--�-!Bs Q 1 Ina-
-b. DOES WELL REPLACE EXISTING WELL? YES❑ NOAE] '•"i°OfQG
c. WATER LEVEL Below Top of Casing: R0 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 RD HAS BEEN PROVIDED E WELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land Surface* �r
* —Z "� 1%
Top of casing terminated at/or below land surface may require Rej
`
a variance in accordance with 15A NCAC 2C.0118 SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
I
e. YIELD(gpm): 2 METHOD OF TEST a i. 'RIN
E PRIN NA E CONSTRUCTING THE WELL
I
Submit the original to the Division of Water Quality within 30 days.Attn:Information?Mgt., Form GW-1a
1617 Mail Service Center-Raleigh, INC 27699-1617 Phone No.[phone] ext1568. Rev.7/05,
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