GW1-2021-04574_Well Construction - GW1_20210429

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RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: HTH 106
KEITH PRESNELL f. DISINFECTION:Type Amount
g. WATER ZONES(depth))
Well C8�tra,_c�tod(d_l�ItGbAY%%L L &PUMP CO., INC. From�O� To From To
YYFiICi YV�L From To From To
Well Contractor Company Name From To From To
P.O.BOX 308
STREET ADDRESS 6.CASING: Thickness/
BOONE NC 286(Y7 Depth Diameter Weight Material
From 0 To 25 Ft 6118 .350 PVC
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 Ft. G..-:.- r lew
SITE WELL ID#(if applicable) From To Ft. 23 BA
STATE WELL PERMIT#(if applicable) From To Ft.
DWQ or OTHER PERMIT#(if applicable) 291021 S.SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply 4 From To Ft. in. in.
DATE DRILLED 4/9/2021 From To Ft.-in. in.
TIME COMPLETED 03:00 AM❑ PM 21 From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
Depth Size Material
CITY: BOONS COUNTY WATAUGA From To Ft.
OFF LARKSPUR TRAIL OFF]USTUS RD OFT CLARK 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 15 DIRT
May be in degrees,
LATITUDE 3 N36;14.701- minutes,seconds or 15 1000 GRAY GRANITE
LONGITUDE W081+39.895 in a decimal format
Latitudellongitude source: LJ(GPS ❑Topographic map
(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 NAME DAN BROWN
STREET ADDRESS%PHIL WASHBURN, 665-BEAST KING ST.
BOONE NC 28607
City or Town State Zip Code
c t_ 964-3130
Area code-Phone number �gSSln�
5.WELL DETAILS: 11.REMARKS: pWR 5ecr011
a. TOTAL DEPTH: 1005 0.5 GPM UNKNOWN,-
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO19
c. WATER LEVEL Below Top of Casing: 500 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
RECORD HAS BEEN PROVIDED 707VE WELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land Surface` Rov�
0 1
"Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C.0118 SIGNATURE OF RT IE L N .OR DATE
e. YIELD(gpm): 0-5 METHOD OF TEST Aar KEITH PRESNELL
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
I �
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.E Rev.7/05
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