GW1-2021-00309_Well Construction - GW1_20210312

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RESIDENTIAL WELL CONSTRUCTION RECORD MAR 19 2021
North Carolina Department of Environment and Natural Resources-Division of Water Quality
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WELL CONTRACTOR CERTIFICATION# ®�,r tlon
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount
56
KEITH PRESNELL g. WATER ZONES(depth):
Well Contractor(Individual Name) From 350 To 351 From To
[)0AEY YVRIGHT VVElL&PUMP CO., INC. From To From TO
Well Contractor Company Name From To From To
STREET ADDRESS P.0.BOX 308 6.CASING: Thickness/
BOONE NC 28607 Depth Diameter Weight Material
From 0 To 92 Ft. d 1/8 IN PVC
City or Town State Zip Code From To Ft.
( 828 )-264-2651 From To Ft.
Area code-Phone number 7.GROUT: Depth Material Method
2.WELL INFORMATION: From 0 To 20 Ft. SENT 1E GravitvFlow
- _N -WELL-- -- - - ----
SITE WELL ID#(if applicable) From _ To Ft."25 BAGS
STATE WELL PERMIT#(if applicable) From To Ft.
DWO or OTHER PERMIT#frf applicable) 262173 8.SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply QK From To Ft. in. in.
DATE DRILLED 215/2021 From To Ft. in. in.
TIME COMPLETED 03:00 AM❑ PM 2 From To Ft. in. in.
9.SAND/GRAVEL PACK:
3.WELL LOCATION:
Depth Size Material
DIN: TODD COUNTY ASHE- From To Ft.
OFF MILT HOUCK OFF LAUREL KNOB RD OFF HW 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) 0 82 DIRT
May be in degrees,
LATITUDE 3 N36'OS.026 minutes,seconds or 82 350 GRAY GRANITE
LONGITUDE _ W081*51.613 in a decimal format 350 351 CREVICE
Latitude/longitude source: L(GPS ❑Topographic map 351 375 BLUE 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 NAME DAVID&KXTHRYN LADD
STREET ADDRESS%WALL TO WALL.CONSTRUCTION 366
FLEEIWOOD NC 28626
City or Town State Zip Code
( (8= - 964-1289
Area code-Phone number
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 375 50 GPM 350-351
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOW
c. WATER LEVEL Below Top of Casing: 100 Fr.. 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 TO THE WELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land Surface* V.471 15o (n;�4
*Top of casing terminated at/or,below land surface may require
a variance in accordance with 15A NCAC 2C.0118 SIG OF CER IF E ELL CONTRACTOR DATE
e. YIELD(gpm): 50- METHOD OF TEST Air KEtTH PRFGN I 1
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 568. Rev.7/05