GW1-2021-01461_Well Construction - GW1_20210329

aSTATE
�yd rw»na D
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 2780 210003
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 127
KEITH PRESNELL g, WATER ZONES(depth):
Well Contractor(Individual Name) From 155 TO 156 From 5 TO 545
OEWEY MIGHT WRL &PUMP CO.. INC. From To From To
Well Contractor Company Name From To From To
STREET ADDRESS F.0.BOX 306 6.CASING: Thickness/
BOONE NC 2WIN Depth Diameter Weight Material
From 0 To 44 Ft. 6119 .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.G From Depth Material Method
From 0 To 20 Ft. BBNTONIT CTlevitYFlaa
SITE WELL ID#(it appaceble) From To Ft. 21 BAGS
STATE WELL PERMIT#(d applicable) From To Ft.
DWQ or OTHER PERMIT#inapplicable) I84919 S.SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply IK FromTo Ft. in. in.
DATE DRILLED 3/3/2021 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
CITY: ZIONVILLE COUNTY Wa 29M From To Ft.
From _To Ft. _
LOT 503 OFF OLD DMIAN OFF HIGHD30UNTAIN N 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) D 5 DIRT
May be in degrees,
LATITUDE 3 N36"10.817 minutes,secondsor 5 U GRANITE
in a decimal lama[
LONGITUDE WOdl+42.610 44 155 BLACK GRANITE
Latitude/longitude source: J GPS ❑Topographic map 155 155 WATER
(location of well must be shown on a USGS topo map and 156 200 GREY GRANITE
attached to this form if not using GPS) 2BO 500 GREY GRANITE
4.WELL OWNER 5DO 540 GRAY GRANITEfQUAF
OWNER'S NAME JEFF KINGREE 540 545 QUART7/WATER
STREET ADDRESSY 545 705 LA['
BANNER ME NC 28604
City or Town State Zip Code
(GM ) 963-7000 -- ch
Area code-Phone number
5.WELL DETAILS: 11.REMARKS: 41, -�C1
a. TOTAL DEPTH: 705 1 rAW LSS-156 3 CTPlIti 540- S45 a
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOW tT_
rJ
e. WATER LEVEL Below Top of Casing: 60 FT. I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WrrH
(Use"+"if Above Top Of Casing) im NCAC M WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO [y/ELL OWNER.
d. TOP OF CASING IS 1 FT Above Land Surface'
Top of casing terminated at/or below land surface may require Dolt 1 l
a variance in accordance with 15A NCAC 2C.0118 SI NATUR O I D WELL 'ONTRAV
30A DATE
e. YIELD(gpm): 4 METHOD OF TEST ek
PRINT 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
L