GW1-2021-06688_Well Construction - GW1_20211007

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RESIDENTIAL WELL CONSTRUCTION RECORD
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North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 7790 } I 210166—
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1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 121
KEITH PRESNELL
g. WATER ZONES(depth):
Well Contractor(Individual Name) From 311 To 312 From To
OEWEY WRIGHT WELL &PUMP CO., INC.
From To From To
Well Contractor Company Name From To From TO
STREET ADDRESS P 0.BOX 30$ 6.CASING: Thickness/
BOONE NC 28 M Depth Diameter Weight Material
From 0 To (53 Ft. 6114 .188 GALV
City or Town State Zip Code From To Ft.
( = )-264-2651 From To Ft.
Area code-Phone number 7.GROUT: Depth Material Method
2.WELL INFORMATION: From 0 To 20 Ft BENTONIT Gravity Flow
24 BAGS -
SITE WELL ID#(if applicable) From To F4.
STATE WELL PERMIT#(if applicable) From TO Ft.
DWQ or OTHER PERMIT#pf applicable) 361292 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Ap$li/17/2021 cable Box): Residential Water Supply From To Ft. in. in.
DATE DRILLED From To Ft. in. in.
TIME COMPLETED AM❑ PA From To Ft. in. in.
9.SAND/GRAVEL PACK:
3.WELL LOCATION:
Depth Size Material
CITY: BOONE COUNTY Wat = From To Ft.
TOWN HOMES OF BROOX—%HRE OFF BROOKSHIRE 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 55 DIRT
36.232693 May in degrees, 55 311 GRAY&BLUE GRANII
LATITUDE 3 minutes,seconds or
LONGITUDE _ -81.651M in a decimal format 311 312 CREVICE
Latitude/longitude source: IN GPS ❑Topographic map 312 SW BLUE GRANITE
(location of well must be shown on a USGS topo map and 500 600 LIGHT OWE GRANITE
attached to this form if not using GPS) 600 760 DARK GRAY GRANITE
4.WELL OWNER
OWNER'S NAME RCPBD INVESTP/ILRITS,LLC
STR �9D�ONEpp��ES
DTG 28607J
City or Town State Zip Code
( (8= 265-6344
Area code-Phone number
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 760 0.5 GPM 311-312
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO)b
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c. WATER LEVEL Below Top of Casing: 150 FT I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
(Use"+"if Above Top of Casing) 15A NCAC 2C,WELL CONSTCTI STANDARDS,AND THAT A COPY OF THIS
ORD HAS`EEN PRO RU
VIDED T 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 OF CE D;WELL CONTRAMF DATE
e. YIELD(gpm): 0.5 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-1a
1617 Mail Service Center-Raleigh, INC 27699-1617 Phone No.[phone] ext 568: Rev.7/05
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