GW1-2021-00276_Well Construction - GW1_20211213

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RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Watei Quality
2780 210062
WELL CONTRACTOR CERTIFICATION#
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1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 105
KEITH PRESNELL
g. WATER ZONES(depth):
Well c� r�Y I viI LL &PUMP CO.. INC. From 374 To 374 From To
From To From To
Well Contractor Company Name From To From To
STREET ADDRESS P.O:BOX 308 6.CASING: Thickness/
BOONE NC 28607 O Depth Diameter Weight Material
105CS 1/8 From To Ft. O r
City or Town State Zip Code From To Ft.
828 264-2651
( )- From To Ft.
Area code-Phone number
MateriaL2.WELL INFORMATION: 7 GROU omT 0 Toth 20 Ff.BENTOFIT Gr8° 'WddW
_ '—"SITE-WELL ID'f(applicable) - -- - -- - --- From __-To_ —Ft`
STATE WELL PERMIT#(if applicable) From To Ft.
DWO or OTHER PERMIT#(if applicable) &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check APR492SW21)� Residential Water Supply From To Ft. in. in.
DATE DRILLED }( From To Ft. in. in.
TIME COMPLETED AM❑ PM❑ From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
LENOIR CALDVn LL Depth Size Material
CITY: COUNTY From To Ft.
2438 DUMB& I"rE RD OFF ZACKS FORK OFF NMA 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 Frr if &A Tation Description
(check appropriate box
39.959956 May be in degrees,
LATITUDE 3 'tT�2 -- minutes,seconds or
LONGITUDE in a decimal format -
Latitude/longitude source GPS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4.WELLOWNER CHARDS&DEBORAH S=ON
OWNER'S NAME
STR TESS
I; 1
City or Town State Zip Code
(252) 230-2204
Area code-Phone number I �L
5.WELL DETAILS: 700 llb 5�370-374 i j ii al.
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOY
200
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 CONSTRUCTIO ANDARDS,AND THAT A COPY OF THIS
1 RE HAS BEEN R IDED TO , E ELL OWNER.
d. TOP OF CASING IS FT.Above Land Surface' . '{�'�]
Top of casing terminated at/or below land surface may require ' OC
a variance in accordance with 15A NCAC 2C.0118 SIGNATURE OF CERTIFIED SWELL CONTRACTOR DATE
e. YIELD(gpm): 0.5 Air METHOD OF TEST KEITH PRESNELL
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
1.
Submit the original to the Division of Water Quality within 30 days.Attn: Information Mgt., Form GW-1a
1617 Mail Service Center-Raleigh,NC 27699-1617 Phone No.[phone] ext 5681 Rev.7/05

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