GW1-2021-03931_Well Construction - GW1_20210823

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RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION#
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1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 57
KEITH PRESNELL
g. WATER ZONES(depth):
Well Contractor(Individual Name) From 157 To 158 From 311 To 312
UEVVEY VVRGH 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 2 W7 Depth Diameter Weight Material
From 0 To 40 Ft. 61/8 .350 PVC
City or Town State Zip Code From To Ft:
( 828 )-264-2651 From To Ft.
Area code-Phone number
2.WELL INFORMATION: 7.GROUT Depth Material Method
From 0 To 20 Ft BENTOIM Chwity Flow
SITE WELL ID#(if applicable) From To Ft:17 BAGS
STATE WELL PERMIT#(if applicable) From To Ft
DWQ or OTHER PERMIT#(if applicable) 336030 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply® From To Ft: in. in.
DATE DRILLED 8/9/2021 From To FtJ in. in.
TIME COMPLETED 03:00 AM❑ PM)l From To Ft; in. in.
3.WELL LOCATION: 9.SAND/GRAVEL PACK:
Depth Size Material
CITY: 'p`S COUNTY From To Ft.
333 FRANK MAST RD OFF BROADSTONE OFF HWY 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 30 DIRT
May be in degrees,
LATITUDE 3 _ N36+14.827 minutes,seconds or 30 157 GREY GRANITE
LONGITUDE _ W081*57.629 in adecimal format 157 158 CREVICE
Latitude/longitude source: ,A GPS ❑Topographic map 158 311 GREY GRANITE
(location of well must be shown on a USGS topo map and 311 319 OUARTZICREVICE
attached to this form if not using GPS) 312 325 GREY GRANITE
4.WELL OWNER
OWNER'S NAMEANNE IRRUINMLANDEM SJOSTRAND
STREET ADDRESSPO BOX 655, ICE L--
VA=CRUCIS NC 2801
City or Town State Zip Code n�C 9,
(3( 36) )-493-5977 s
Area code-Phone number r+�ti031 i
5.WELL DETAILS: 11.REMARKS: t
a. TOTAL DEPTH: 325 1 GPM 157- 158 41GPM 311 -312
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO)ir1
c. WATER LEVEL Below Top of Casing: 40 FT. I WE DO HEREBY CERTIFY THAT THIS LL 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
tBEEN PROVI ED HE WELL OWNER.
d. TOP OF CASING IS 1 - FT.Above Land Surface* I j �y��
Top of casing terminated at/or below land surface may require Q 0 rp 1.4 1.,
a variance in accordance with 15A NCAC 2C.0118 9IGPJ URE OF GER11FIED WELL CONTRA OR DATE
e. YIELD(gpm): 5 METHOD OF TEST Air 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-1 a
1617 Mail Service Center-Raleigh,NC 27699-1617 Phone No.[phone] ext 568R 1 Rev.7/05
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