GW1-2021-07103_Well Construction - GW1_20210915

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RESIDENTIAL WELL CONSTRUCTION RECORD
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�C North Carolina Department of Environment and Natural Resources-Division of Water Quality
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WELL CONTRACTOR CERTIFICATION# 2780 i 200017
1.WELL CONTRACTOR: HTH
KEITH PRESNELL f. DISINFECTION:Type Amount 121
g. WATER ZONES(depth):
Well Contractor(Individual Name) From 317 To 318 1 From 668 To 669
UtVVtY VYkItaH l YVtLL&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. 2WT Depth Diameter Weight Material
From 0 To 60 Ft 61/8 .350 PVC
City or Town State Zip Code From To Ft:
( $2$ )-264-2651 From To Ft:
Area code-Phone number
7.GROUT: Depth ! Material Method
2.WELL INFORMATION: From 0 To W Ff,BENTONTT GmitYFlow
-- _-- —. ___ --- -- , _ -
SITE WELL—ID#(if—applicable—)----- —_ From To Ft:- BAGS B_GS----
STATE WELL PERMIT#(if applicable) From To Ft.
DWQ or OTHER PERMIT#(if applicable) 195185 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply From To Ft. in. in.
DATE DRILLED 91312021 From To Ft. in. in.
TIME COMPLETED 03•00 AM❑ PM& From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
Depth Size Material
CITY: BOONS COUNTY From To Ft.
OFF HARMONY LN OFF FRIENDSM CHURCH RD 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 50 DIRT
N36'16.$76 May be in degrees,
LATITUDE 3 minutes,seconds or 50 317 GRAY GRANITE
LONGITUDE _ W081*52.606 in a decimal format 317 318 QUARTZ
Latitudellongitude source: Ig GPS ❑Topographic map 318 658 DARK GRAY GRANITE
(location of well must be shown on a USGS topo map and 668 659 QUARTZICREVICE.
attached to this form if not using GPS) 669 705 ,r..t� LIGHT GRAY GRANITE.
4.WELL OWNER
OWNER'S NAMES MA=- G
--STREETADDRESSIO BOX 1451, 2OL�
BOONE NC 2MM-.
City or Town State Zip Code
262-3366 �
Area code-Phone number
SWELL DETAILS: 705 110.5 REMARKS:
M 17-318 1 1.5 GPM 6%-6W
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO)lb
c. WATER LEVEL Below Top of Casing: 100 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
RECORD HAS BEEN PROVIDE THE WELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land Surface' I
Top of casing terminated at/or below land surface may require /
a variance in accordance with 15A NCAC 2C.0118 SIGNATURE O IFIED WELL(ONTRoDrTOR DATE
e. YIELD(gpm): 2 METHOD OF TEST Aar KEITH PRESNELL
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
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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 566. Rev.7/05
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