GW1-2021-06603_Well Construction - GW1_20211007

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
2780 1 j 210091
WELL CONTRACTOR CERTIFICATION# E
k
I
1.WELL CONTRACTOR: f. DISINFECTION:Type fHTH Amount 23
KEITH PRESNELL
g. WATER ZONES depth):
Well Contractor: IDdividu llvatTt>�. . From 125 To i 6 From To
UEVVEY 1GA I VYELL FUME C0., INC.
From To From To
Well Contractor Company Name From To From To
STREET ADDRESS P.0.BOX 308 6.CASING: Thickness/
BOONE NC 28607 Depth Diameter Weight Material
From 0 To 100 Ft. 6118 .3509 PVC
City or Town State Zip Code From To Ft.
( = )7-2651 From To Ft.
Area code-Phone number
7.GROUT: Depth Material Method
2.WELL INFORMATION: From 0 To 20 Ft BENTONIT &avityFlow
-- - — — - --
SITE WELL ID#(if applicable) From To Ft.
STATE WELL PERMIT#Cd applicable) From To Ft.
DWQ or OTHER PERMIT#(if applicable) 8.SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply From To Ft. in. in.
9/15/2021
DATE DRILLED From To Ft. in. in.
TIME COMPLETED AM❑ PA From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
FLEETWOOD ASl;g Depth Size Material
CITY. COUNTY From To Ft.
OFF OUR LITTLE CIRCLE OFF TROD"HORSE CM 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) 0 100 DIRT
May in degrees, 100 125 GRANITE
LATITUDE 3 minutes,seconds or
LONGITUDE in a decimal format 125 126 QUARTZMfATER
Latitude/longitude source: GPS ❑Topographic map 126 130 QUARTZ
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4.WELL OWNER
OWNER'S NAMENASH CORMNE -BORN AGAIN
STREET ADDRES ° A
DEEP GAP NG 28618
City or Town' State Zip Code
964-6610
cess��
Area code-Phone number ,�ID1R c�eCit•0
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 130 50 GPM 125-126
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOX]
c. WATER LEVEL Below Top of Casing: 20 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
RECQBDJ1AS BEEN PROVIDED Tqtfo WELL 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 SIGNATURE AGE WIED WELL CONTRItr DATE
i
e. YIELD(gpm): S0 METHOD OF TEST Ai KEITH PRESNELL i
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
i
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

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