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HomeMy WebLinkAboutGW1-2022-01233_Well Construction - GW1_20220103 SrAlgo RESIDENTIAL WELL CONSTRUCTION RECORD North Carolina Department of Environment and Natural Resources-Division of Water Quality WELL CONTRACTOR CERTIFICATION# 2780 210231 1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 56 KEITH PRESNELL g. WATER ZONES(depth): Well COo9tra�cto`/r Indi IGHT Nam 246 &PUMP CO., INC. From 2` To 249 From To From To From To Well Contractor.Company Name From To From To P.O.BOX 308 STREET ADDRESS 6.CASING: Thickness/ BOONE NC 28607 From OD oth 175 Ft Diameter W6 1/8eight Material City or Town State Zip Code From To Ft. 0 ( 828 )-264-2651 From To Ft. Area code-Phone number " 7.GROUT: Depth ! Material Method 2.WELLINFORMATION- From O To 20 Ft.BENTONIT Gravity Flow SITE WELL"ID#(if applicable) ---From _ -To Ft-_ - — - - —- STATE WELL PERMIT#(ifapplicable) From To Ft. DWQ or OTHER PERMIT#(f applicable) WYlyy &SCREEN: Depth Diameter Slot Size Material WELL USE(Check Ap gl/30/2021 licable Box): 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: Depth Size Material CITY: LENOIR COUNTY CALDWELL From To Ft. 7063 RICHLAND RD OFF RICHLAND RD OFF 321 From _To From--TO- Ft. (Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) Ft. o„ ,ly/pn TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG .f ❑Slope ❑Valley El Flat ❑Ridge ❑Other From To Formation DbSti'Ii�orll 202? (check appropriate box) 0, 150 DIRT May be in degrees,LATITUDE 3 minutes,seconds or 150 162 SHALE WT LONGITUDE in a decimal format 162 246 GR l7JrEQSfNG UNE Latitude/longitude source: A GPS ❑Topographic map 246 249 QUARTZ (location of well must be shown on a USGS topo map and 249 360 GRANITE attached to this form if not using GPS) 350 374 SHALE 4.WELL OWNER 374 425 GRANITE OWNER'S NAMES Sl"= STREET ADDRESS1752 COTTON BARER COURT COR9=S NC 28031 City or Town State Zip Code (( SM )-312-9438 Area code-Phone number 5.WELL DETAILS: 11.REMARKS: a. TOTAL DEPTH: 425 6 GPM 246-249 b. DOES WELL REPLACE EXISTING WELL? YES❑ NOXI c. WATER LEVEL Below Top of Casing: 150 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 TO TPk WELL OWNER. d. TOP OF CASING IS 1 FT.Above Land Surface* L _ / *Top of casing terminated aVor below land surface may require a variance in accordance with 15A NCAC 2C.0118 1" 00AIZ1,2 SIGNATURE OF CERTIFIED VVITtl CONTRMTOR DA E e. YIELD(gpm): 6 METHOD OF TEST Air KEITH PRESNELL 1. PRINTED NAME OF PERSON CONSTRUCTING THE WELL Submit the original to the Division of Water Quality within 30 days.Attn: Information Mgt.; Form GW-1a 1617 Mail Service Center-Raleigh,INC 27699-1617 Phone No. (919)733-7015 ext 568. Rev.7/05 �40 r moo;r 3A]