GW1-2021-02148_Well Construction - GW1_20210620

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RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR:
KEITH PRESNELL f. DISINFECTION:Type HTH _Amount 39
g. WATER ZONES(depth):
Well Contractor(Individual Name) From 65 To From 105To 108
UEVVtY VVKIGH T VVELL &PUMP CO.. INC. From 160 To 165 From To
Well Contractor Company Name From To From To
STREET ADDRESS P. O.BOX 30$ 6.CASING: Thickness/
BOONE NC 2$B07 Depth Diameter Weight Material
From 0 To 27 Ft.__ 6 1/4 .188 GALV
City or Town State Zip Code From To Ft.
( $2$ )- 264-2651 From To Ft.
Area code-Phone number
2.WELL INFORMATION: 7.GROUT: Depth Material Method
From 0TO 20 Ft. BENTONU Gravity Flow
SITE WELL ID#(if applicable) From To Ft.. 33 BAGS
STATE WELL PERMIT#(if applicable) From To Ft.._
DWQ or OTHER PERMIT#(if applicable) 331048 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply LX From To Ft._ in. in.
DATE DRILLED &2/2021 From To Ft. in. in.
TIME COMPLETED 03:00 AM❑ PM CX From To Ft._ in. in.
9.SAND/GRAVEL PACK:
3.WELL LOCATION:
Depth Size Material
CITY: LAUREL ACTS COUNTY A_S1E From To Ft.
OFF CRANBERRY CREEK RD OFF HWY 221 OFF TO From _To Ft._ _
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) From To Ft._ _
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
❑Slope ❑Valley ❑Flat ❑Ridge ❑Other From To Formation Description
(check appropriate box) 0 17 CLAY/GRAVEL
May be in degrees, --
LATITUDE 3 N36*2$.100 minutes,seconds or 17 65 —_ GRANITE
LONGITUDE W081*19.525 in a decimal format 65 65 —_ CREVICE
Latitude/longitude source: JCPS ❑Topographic map 65 105 GRANITEIQUARTZ
(location of well must be shown on a USGS topo map and 105 108 VOID
attached to this form if not using GPS) 108 160 QUARTZ
4.WELL OWNER 160 165 VOID
OWNER'S NAME CAM SANDS 165 200 GRANITE
STREET ADDRESS PO BOX 126,
JEFFERSON NC 2$644
City or Town State Zip Code Id V
( (336))_ 977-9$6$
Area code-Phone number In{0(C�3 IR SecY on
"NA5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 200 7 GPM 65- 5 GPM_. 105- 108
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO Q 1$GPM 160-165 _
c. WATER LEVEL Below Top of Casing: 15 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 ROVIDED TO E WELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land Surface' ' /
Top of casing terminated at/or below land surface may require v/ (�
a variance in accordance with 15A NCAC 2C.0118 LZ
SIGNATURE OF CERTIFIED WELL CON RA OR DATE
e. YIELD(gpm): 30 METHOD OF TEST Au KEITH PRESNELL
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, NC 27699-1617 Phone No. [phone] ext 568. Rev.7/05

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