GW1-2021-03932_Well Construction - GW1_20210823

RESIDENTIAL WELL CONSTRUCTION RECORD
- North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 2780
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 120
KEITH PRESNELL
g. WATER ZONES(depth):
Well c6g r r(�gcjif�GiAl�lame)LL &PUMP CO., INC. From 240 To 241 From To
`� From To From To
Well Contractor Company Name From Tq—j From TO
STREET ADDRESS P.O.BOX 30$ 6.CASING: Thickness/
BOONE NC 28607 Depth Diameter Weight Material
From 0 To 67 Ft.• 61/8 .350 PVC
City or Town State Zip Code From To Ft:
( = )-264-2651 From To Ft.
Area code-Phone number
2.WELL INFORMATION: 7.GROUT: Depth Material Method
From 0 To 20. Ft BENTONIT Gravity Flow
SITE WELL ID#(if applicable) From To Ft.,
STATE WELL PERMIT#(if applicable) From To Ft.
DWQ or OTHER PERMIT#(d applicable) ACT V EIL &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply® From To Ft:' in. in.
DATE DRILLED - 8/5/2021 From To Ft in. in.
TIME COMPLETED 03:00 AM❑ PM From To Ft in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
Depth Size Material
CITY: BOONE COUNTY - Wat8MA From To Ft.
OFF EVER.GPOW LN OFF EASTBROOK OFF CBE RR 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 s N36+02.158 minutes,seconds or 50 240 GRANITE
LONGITUDE W081*24.793 In a decimal format 240 241 CREVICE
Latitude/longitude source: LXGPS ❑Topographic map 241 450 GRANITE
(location of well must be shown on a USGS topo map and 460 465 QUARTZ
attached to this form if not using GPS) 465 800 . GRANITE
4.WELL OWNER
OWNER'S NAMERONALD&CHERYL STANL.EY
STREET ADDRESS174 OMRGREEN LN:- -
BOONE, NC 286(71 �a
City or Town State Zip Code
( (8287 -773-2605 , � 26\2
Area code-Phone number �U�% §S tvt111
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: g00 1 GPM 240-241 udC j3 Se-
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOJO7
I
c. WATER LEVEL Below Top of Casing: FT. I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
(Use"+"if Above Top of Casing) 15A NCAC 2C,WELL CON TRUCTION STANDARDS,AND THAT A COPY OF THIS
R HAS BEEN PR971DED TO 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 I D W ONTR R DATE
e. YIELD(gpm): 1 METHOD OF TEST Aar KEITH PRESNELL i
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 568� Rev.7/05
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