GW1-2022-01417_Well Construction - GW1_20220124

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RESIDENTIAL WELL CONSTRUCTION RECORD
�C North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 2780 I 210077
1.WELL CONTRACTOR: i
f. DISINFECTION:Type HTH Amount 76
KEITH PRESNELL
g. WATER ZONES(depth)'.
Well Contractor(Individual Name) From 500 To 600 From To
UtVVE VVkiGH I WELL &,PUMP CO.. iNL. From To From To
Well Contractor Company Name From To From To
STREET ADDRESS P.0.BOX 308 6.CASING: Thickness/
BOONS NC 28607 Depth Diameter Weight Material
From 0 To 105 Ft. 61/4 .188 GALV
City or Town State Zip Code From To Ft.
( US )264-2651 From To Ft.
Area code-Phone number
2.WELL INFORMATION: 7.GROUT: Depth Material Method
From 0 To 20 Ft.BENTONTT Gravity Flow
- -�- SITE WELL=ID_#(if-applicable)___ __.-___ _ ________ _ _e From To Ft.64 BAGS
STATE WELL PERMIT#(if applicable) From To Ft.
DWO or OTHER PERMIT#(if applicable) 137279 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply® From To Ft. in. in.
DATE DRILLED 1/11/2022 From To Ft. in. in.
TIME COMPLETED 03:00 AM❑ PMXJ From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
Depth Size Material
CITY: Z1010v .ZE COUNTY W94W From _To Ft.
1115 REPLOGLE DR OFF REPLOGLE DR OFF HOWA _ 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 90. MUDfB )ULDERS
May be in degrees,
LATITUDE 3 N36*13.960 minutes,seconds or 9D 390 GRAY GRANITE
LONGITUDE W081+44.835 in a decimal format 390 SW BLUE GRANITE
Latitude/longitude source: ®GPS ❑Topographic map 500 885 DARK GRAY GRANITE
(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 NAMEC FIRTSTO•IRM C GIMTMS11SAALW CIM f
STREET ADDRESa)O BOX -2238 •-
B ONE NC 22607
City or Town State Zip Code 2 4
((8= )-620-2M "
Area code-Phone number
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 895 0 25 GPM 500-ISM
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO)p
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 BEE 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 -/ "�� CZ
a variance in accordance with 15A NCAC 2C.0118 SIGNATURE OF CERTIFIED'WELL CONTRACTUP ATE
e. YIELD(gpm): 0.25 METHOD OF TEST Air kO=IIH PPEShIE 1l
PRINTED NAME OF PERSON!CONSTRUCTING THE WELL
f
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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