GW1-2021-04439_Well Construction - GW1_20210811

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR:
KEITH PRESNELL f. DISINFECTION:Type HTH Amount 34
g. WATER ZONES(depth):!
Well Contractor(Individual Name) From 130 To 135 From To
DE5/VEY WRiGH T WELL &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 1 Diameter Weight Material
From 0 To 110 Ft. 61/8 .360 - PVC
City or Town State Zip Code From To Ft.
( = )254-2651 From To Ft.
Area code-Phone number 7.GROUT- Depth Material Method
2.WELL INFORMATION: From 0 To 20 Ft,BENTONTT GtraviwFlow
--- - -- - 18 BAGS
SITE WELL ID#(if- applicable) From To Ft', -_
STATE WELL PERMIT#(if applicable) From To Ft.
DWQ or OTHER PERMIT#(if applicable) 303598 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply From To Ft. - in. in.
DATE DRILLED 7/24/2021 From To Ff. in. in.
TIME COMPLETED 03:00 AM❑ PMX From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
Depth Size Material
CITY: BOONE COUNTY VF=Wa From To Ft.
OFF LITTLE LAUREL OFF 8ANMOO OFF DEERFM 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
May be in degrees,
LATITUDE 3 minutes,seconds or 50 70 ROCK
LONGITUDE in a decimal format 70 90 CLAY
Latitude/longitude source: Of GPS ❑Topographic map 90 95 ROCK
(location of well must be shown on a USGS topo map and 95 102 SANDSTONE
attached to this form if not using GPS) 102 130 ,GRANITE
4.WELL OWNER 130 135 ! VOID
OWNER'S NAMETOM&JEN14UM VAN GA DER 135 200 GRANITE
STREET ADDRESS184 DEERFIELD FOREST PKWY,
BOONS - NC 28607
City or Town State Zip Code
(( SM )_773-46W
Area code-Phone number AUG
I G
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 200 20 GPM 130-135 .M�t;fl;1 i'rCCeSSing Unit
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOXI DV1
c. WATER LEVEL Below Top of Casing: 40 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 ROVI TO THE WELL OWNER.
d. TOP OF CASING IS 1 FT Above Land Surface' 5) BEEN
�
'Top of casing terminated at/or below land surface may require 17
a variance in accordance with 15A NCAC 2C.0118 SIGNATURE OF CERTIFIEDWEI L CO A R DATE
e. YIELD(gpm): 20 METHOD OF TEST Ali' 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-1a
1617 Mail Service Center-Raleigh,NC 27699-1617 Phone No.[phone] ext 568 R I Rev.7/05

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