GW1-2022-01416_Well Construction - GW1_20220124

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RESIDENTIAL WELL CONSTRUCTION RECORD
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c North Carolina Department of Environment and Natural Resources-Division of Water Quality
w WELL CONTRACTOR CERTIFICATION# 27$4 210148
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1.WELL CONTRACTOR: f. DISINFECTION:Type i HTH Amount 127
KEITH PRESNELL
g. WATER ZONES(depth):
Well Contractor(Individual Name) From To From To
WL—V&Y-WH1(6H+'ALL PUMPCzE1., IfV(C. From To From TO
Well Contractor Company Name From To From TO
STREET ADDRESS A O.BOX 308 6.CASING: Thickness/
Depth Diameter Weight Material
BOONE NC 2$607
From To 21 Ft. 6 144 Us T�, zr
City or Town State Zip Code From To Ft.
( _)-264-2651 From To Ft.
Area code-Phone number 7.GROUT: Depth Material Method
2.WELL INFORMATION:
From 0_To 20 Ft.MUM= f'agggimmew
—S1--TE_WELL ID_#(ifapplicable)_ _ —___ _____—From__-To —Ft.14MAGS_—
STATE WELL PERMIT#(if applicable) From To Ft.
DWO or OTHER PERMIT#(if applicable) AG ItUL &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply From To Ft. in. in.
DATE DRILLED 12/16/2021 From To Ft. in. in.
TIME COMPLETED 03:00 AM❑ PM$l From To Ft. in. in.
3.WELL LOCATION: 9.SAND/GRAVEL PACK:
Depth Size Material
CITY: LINVI 7 F COUNTY AVERY From TO Ft.
1725 FOREST RIDGE DR IN LINVILLB RIDGE OFF H 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) ft 2 DIRT
May be in degrees,
LATITUDE 3 jjj 105$�— minutes,seconds or 2 111 GRANITF
LONGITUDE -R1 990623 in a decimal format 111 i29_ SHALE
Latitude/longitude source: W GPS ❑Topographic map 129 3M GRANITE
(location of well must be shown on a USGS topo map and SM 342-
(3LIARTZ
attached to this form if not using GPS) A2 sin f'RANITF
4.WELL OWNER sin 530 QUARTZ
OWNER'S NAMESCOTT I1JTGERT SW 704 - GRANITE
STREET ADDRES3'r 0 704 720 SHALE .
BOONE NC 2$62 GRANITE j I
City or Town State Zip Code
(( $2$) 1-??3-16$5 JAN 2 4 2617"
Area code-Phone number
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: $00 2 GPM 330-342 .3.5 GPM 510'-530
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO)U
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 PROVID 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 o/^ V
a variance in accordance with 15A NCAC 2C.0118 SIGNATURE OF CERTIFIED'WELLL CONTRACTOR DATE
e. YIELD(gpm): 5.5 METHOD OF TEST Air '
PRIN F M O N CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days.Attn:Information'jMgt., Form GW-1a
1617 Mail Service Center-Raleigh,NC 27699-1617 Phone No.[phone] ext 568. Rev.7/05
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