GW1-2021-07436_Well Construction - GW1_20210921

RESIDENTIAL WELL CONSTRUCTION RECORD
NoeC� arolina Department of Environment and Natural Resources-Division of Water Quality
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WELL CONTRACTOR CERTIFICATION#
1.WELL'CONTRACT80
f. DISINFECTION:Type HTH Amount`
.e KEITH PPE%J g. WATER ZONES(depth):
Well_Contractor(Individual.Name)',{3 o From 117 To 118 From TO
DEWEY k) .IGHT WELL &PUMP CO., INC.
• -j--Y From To From To
Well„Contractor Corinpany Name From To From+
' P.O/tb&303, Ott
STREET ADDRESS, 6.CASING: Thickness/
BOONENC ° 28f�47 Depth Diameter Weight M�ateria
From U To ZC5 Ft. d lie a3
City or Town;, State Zip Code From To Ft.
Tn , )m.264P 2465,1
Area code-Phone-number From To Ft.
7.GROUT: Depth Material Method
2 W,ELL INFORMATION
From 0 To 21 Ft.BENT "
1r. IT L ID#(i appiiicabie);`� - -- _ ..From To Ft. r�+�
i�
t STATE WELL PERMIT#(if applicable) From To Ft: ;"
'DWQ or OTHER PERMIT 0 applicable) 2B0'.J3 &SCREEN: Depth Diameter;L Slot Slze rr
..-, P .Material
WELL USE(Check Applicable Box): Residential Water Supply LN From To Ft. in.
DATE DRILLED W30/2021 From To Ft. in. in
TIME COMPLETED 63:00 AM❑ PM From To Ft-' in: ' a, in.
4.SAND/GRAVEL PACK:
&WELL LOCATION:
Depth Size Material
ti
CITY: =01;V=1 COUNTY ;T==g From - To Ft.
OFY WIL"COMBS HOLLOW OFF SMVER-1- ONE OF
From TO Ft.
From _To .Ft:
1 (Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code)
is
TOPOGRAHIC/LAND SETTING: 10.DRILLING LOG
❑Slope ❑Valley ❑Flat ❑Ridge ❑Other From To Formation Description
(check appropriate box) 0 5 DIRT
May be in degrees,
LATITUDE 3 N36W.035 minutes,seconds or 5 117 BLUE GR,
LONGITUDE W00,81*4 i.24,S in a decimal format 117 118 CREIvICE/QUAPTZ
Latitude/longitude source: LXGPS U Topographic map 118 303 BLUE GP,ANITE
(location of well must be%own on a USGS topo map and 303 304 CREVICE
attached to this form if n3f using GPS) 304 325 BLUE GRADITE'
4.WELL OWNER
OWNER'S NAME=' S77AX LANIZE ������/�
STREET ADDRESS BOX 126,
VILA.S NC 28592 ' c C D 1 �n�i
City or Town State Zip Code
a( 33� Information Processing Unit
Area code-Phone number DWR SgcT!on
5.WELL DETAILS: - 11.REMARKS:
a. TOTAL DEPTH: 325 0.5 GPM 117- 11$ 29.5 GPIA 303- 304
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOW
c. WATER LEVEL Below Top of Casing: 40 8`-', 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 PR VIDED TO THE WELL OWNER.
d. TOP OF CASING Is 1 FT.Above Land Surface' •�
3- *Top of casing terminated at/or below land surface may require tJ
"x a variance in accordance with 15A NCAC 2C.0118 - i-`
SIGN l7R F C TIFIEE3 E CbN �%OR DATE_
e. YIELD(gpm): 30 METHOD OF TEST KEITH PPESNELL
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,INC 27699-1617 Phone No.[phone] ext 568. Rev.7/05
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