GW1-2021-00541_Well Construction - GW1_20210219

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3O5' RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 27$0 200112
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 58
KEITH PRESNELL
g. WATER ZONES(depth):
Well Contractor(Individual Name 77 78 292 294
DEWEY VVRI(BHT L&PUMP CO., INC. From To From To
From To From To
Well Contractor Company Name From To From To
STREET ADDRESS P.O.BOX 308, 6.CASING: Thickness/
BOONB NC 2MM Depth Diameter Weight Material
From 0 To 73 Ft. 6114 .188 GALV
City or Town State Zip Code From To Ft.
( 828 )-2.64-2651 From To Ft.
Area code-Phone number
2.WELL INFORMATION: 7.GROUT: Depth Material Method
From 0 To 20 Ft. BENTONU Gravlt9Flow
SITE WELL ID#-ofapplicable) From To Ft. 26B►GS
STATE WELL PERMIT#(if applicable) From To Ft.
DWQ or OTHER PERMIT#(f applicable) AG WELL &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply CX From To Ft. in. in.
DATE DRILLED 2/10/2021 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: LENIOR COUNTY CALDWELL From To Ft.
OFF BRUSHY PLACE OFF OLD MORGANTON RD O From _To Ft.-
From--TO Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
❑Slope ❑Valley Cl Flat ❑Ridge ❑Other From To Formation Description
(check appropriate box) O 60 CLAY/MUD/GRAVEL
_ _ N3553.189 May in degrees,
LATITUDE 3 + minutes,seconds or 60 77 BLUE GRANITE
LONGITUDE _ Wo$1;34.671 in a decimal format n 78 QUARTZICREMCE
Latitude/longitude source: L)(GPS ❑Topographic map 78 292 GRAY GRANITE
(location of well must be shown on a USGS topo map and 292 294 BIG CREVICE
attached to this form if not using GPS) 294 305 GREY&BLUE GiANl7
4.WELL OWNER
OWNER'S NAMEROGER COFFSY
STREET ADDRESS5016 VALLEY VIEW CIR,
IMHOR NC 28645 _
City or Town State Zip Code
( (8M )_ 754-7157
Area code-Phone number
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 305 1 GPM 77-78 74 GPM 292-294
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO IQ.
c. WATER LEVEL Below Top of Casing: 15 FT I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
(Use"+"if Above Top of Casing) t 5A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
RECORD HA BEEN PROVIDED TO T ELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land Surface'
Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C.0118 IGNA U E OF CERTIFIED WELL NTRACTW DATE
e. YIELD(gpm): ?5 METHOD OF TEST Air KEITH PRESNELL
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,INC 27699-1617 Phone No.[phone] ext 568. Rev.7/05