GW1-2021-06692_Well Construction - GW1_20211007

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6�c.STATFo � I
.: RESIDENTIAL WELL CONSTRUCTION RECORD
. o North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 27$0 2100091-1
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 36
KEITH PRESNELL
g. WATER ZONES(depth):''
Well Contractor Individual Name From 150 To 151 From To
DEWEY iGHT LL&.PUMP CO., INC.
From To From To
Well Contractor Company Name From To From To
P.O.BOX 30$ Thickness/
STREET ADDRESS 6.CASING:
BOONE NC 2MM Depth Diameter Weight Material
From 0 To 35 Ft'. 6114 .I38 GALV
City or Town State Zip Code From To Ft.
( $28 ) 264-2651 From To Ft.
Area code-Phone number
7.GROUT-. Depth Material Method
2.WELL INFORMATION: From 0 To 20 Ft.BENTONTT Gravity Flow
SITE WELL ID#(if applicable) From - To Ff.22 BAG5
STATE WELL PERMIT#(if applicable) 330516 From To Ft.
DWQ or OTHER PERMIT#ff applicable) &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply From To Ft. in. in.
DATE DRILLED 9/18/2021 From To Ft. in. in.
TIME COMPLETED AM❑ PA From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
Depth Size Material
CITY. VTt_AC COUNTY Wflta= From To Ft.
OFF FRANK BROWN RD OFF VANDERPOOL RD OF From _To Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) From To Ft.
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
❑Slope ❑Valley ❑Flat ❑Ridge ❑Other From To Formation Description
(check appropriate box) 0 25 BOULDERS/GRAVEUK
N36*19.995 May be in degrees, 25 150 BLUE GRANITE
LATITUDE 3 minutes,seconds or
LONGITUDE _ in a decimal format 150 151 CREVICE/QUARZ
Latitude/longitude source: 2S GPS ❑Topographic map 151 205 GRAY GRANITE
(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 NAMEJOHN BROWNFKANK BROWN RD, 01b
STREL/�D,pRES
vv 1111..tXi.��
City or Town State Zip Code
((8M 964-2020
Area code-Phone number 3
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 205 1 GPM 150-151
b. DOES WELL REPLACE EXISTING WELL? YES❑ NA
c. WATER LEVEL Below Top of Casing: 30 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
1 RECO HA BEEN PROVIDED TID TH OWNER.
d. TOP OF CASING IS FT.Above Land Surface*
*Top of casing terminated at/or below land surface may require a
a variance in accordance with 15A NCAC 2C.0118 SI ATURE OF CERTIFIED ELL CONTRALTO DATE
1 Air KEITH PRESNELLI
e. YIELD(gpm): METHOD OF TEST
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-1a
1617 Mail Service Center-Raleigh, INC 27699-1617 Phone No.[phone] ext 566 Rev.7/05
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