GW1-2021-01460_Well Construction - GW1_20210329

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5 g RESIDENTIAL WELL CONSTRUCTION RECORD
5y North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: f, DISINFECTION:Type HTH Amount 64
KEITH PRESNELL g. WATER ZONES(depth):
Well Contractor(Individual Name) FrdlalKN0AH1 TO DRY HQLE From TO
DEVVEY'ARIGHT Vii&PUMP CO., INC. From To From To
Well Contractor Company Name From To From To
STREET ADDRESS P.O.BOX 308 6.CASING: Thickness/
BOONE NC 28607 Depth Diameter Weight Material
From 0 To---45- Ft. 61/9 .350 PVC
City or Town State Zip Code From To Ft.
( M8 )-264-2651 From To Ft.
Area code-Phone number
2.WELL INFORMATION: 7.GROUT: Depth Material Method
From 0 To 20 Ft. RRNTANTT GrsoitYRirs
SITE WELL ID#fa applicable) From To Ft. 1RRACt$
STATE WELL PERMIT#ld applicable) From To Ft.
DWQ or OTHER PERMFr#fn applicable) 291021 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply Q From To Ft. in. _in.
DATE DRILLED W171=1 From To Ft. in. —in.
TIME COMPLETED 03:00 AM❑ PM N From To Ft—in. in.
9.SAND/GRAVEL PACK:
3.WELL LOCATION:
Depth Size Material
clw. DRY HOLE COUNTY W>tt = From To Ft.
OFF LA.R.KSPQR TPUML OFF JU MS RD OFF CLARK From _To Ft. _
From To Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Pamel,Zip Code)
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
❑Slope ❑valley ❑Flat ❑Ridge ❑Other From TO Formation Description
(check appropriate box) D 35 DIRT
May be in degrees,
LATITUDE 3 WWI4.701 minutes,seconds or 35 AS GRAY GRANITE
LONGITUDE W081*39.895 In a decimal format 111IR Sfln GRAY X I IMF GRFFN
Latitude/longitude source: CkGPS ❑Topographic map —500 1000 GR AY/0'I IFIGREEN G
(location of well must be shown on a USGS topo map and irm 1205 Fit !'GRANITF
attached to this form if not using GPS)
4.WELL OWNER YY L>+
OWNER'S NAME DAN At TR AMY RRO MIN
STREET ADDRESS%P�W CHA _RIJRN, 611 7ANT KING ST
BOONE NC 2R607 MAR 2 9
City or Town State Zip code
LSS�J 04-3130
Area code-Phone number
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 1205 013 GPM ITNKNOU N_nRY H01 R
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOW
c. WATER LEVEL Below Top of Casing: SIN FT. I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
(Use"+"if Above Top of Casing) 15A N.2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
R5QORD HAS BEEN PROVID O THE WELL OWNER.
d. TOP OF CASING IS 1 Fr.Above Land Surface' l
Top of casing terminated at/or below land surface may require 3 a�
a variance in accordance with 15A NCAC 2C.0118 SIGNATURE OF CERTIFIELTVVELL COITMCTOR DATE
e. YIELD(gpm): 0.13 METHOD OF TEST Air KEITH PRFGNFI 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-1a
1617 Mail Service Center- Raleigh, NC 27699-1617 Phone No. [phone] ext 568. Rev.7/05