GW1-2021-05884_Well Construction - GW1_20211025

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- --- RESIDENTIAL WELL CONSTRUCTION RECORD
cQ North Carolina Department of E vn ironment-andNatural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION#
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1.WELL CONTRACTOR: f. DISINFECTION:Type HIH Amount 27
KEITH PRESNELL g. WATER ZONES(depth):
Well Contractor(Individual Name) From t," To123 From tan Toagi
OEWEY WEIGHT VVELL &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$607 Depth Diameter Weight Material
From 0 To (2 Ft. 6118 .350 PVC
City or Town State Zip Code From To Ft.
( 828 )264-2651 From To Ft.
Area code-Phone number 7.GROUT: Depth Material Method
2.WELL INFORMATION: _ — ---
_. __-_-- From- 0__To�-Ft:C�irleilt
SITE WELL ID#(if applicable) From To Ft.
STATE WELL PERMIT#(if applicable) VAW1253 From To k i
I
DWQ or OTHER PERMIT#(if applicable) 1SM61 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply 50 From To Ft. in. in.
DATE DRILLED 9/28/2021 From To Ft. in. in.
TIME COMPLETED 03:00 AM❑ PMS] From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
Depth Size Material
CITY- FLEE.TWOOD COUNTY ASHE From TO Ft.
415 CEDAR TRAIL OFF VIM FINE SWAMP OFF HW 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) p 58 DIRT
May be in degrees,
LATITUDE 3 36 258086 minutes,seconds or SR 1" inR ANITF
LONGITUDE -91.495648 in a decimal format 122 123 QUARTZ
Latitude/longitude source: IA GPS ❑Topographic map 123 180 GRANITE
(location of well must be shown on a USGS topo map and 180 183 QUARTZ
attached to this form if not using GPS) 183 205
4.WELL OWNER
OWNER'S NAMERONALD&BENITA HERNANDEZ
_._. STFIEET ADDRESSnO 803�Z93.., _ ,?
t
SUPPLY NC 28462 � �Owpp p cle
City or Town State Zip Code -
(9( 10) 1-742-1996
Area code-Phone number
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 205 2 GPM 122- 123 8 GFM 180- 193
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO)F7
C. WATER LEVEL Below Top of Casing: 70 FT I DO HEREBY CERTIFY THAT THISwELL 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 BEEPPROVJEQ TO THE 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 SIG AURE CERTIFIED WELL ACTOR DATE
e. YIELD(gpm): 10 METHOD OF TEST Air KEITH PF2F4;IVFI I
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-1 a
1617 Mail Service Center-Raleigh, NC 27699-1617 Phone No.[phone] ext,,568• Rev.7/05
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