GW1-2021-02729_Well Construction - GW1_20210901

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RESIDENTIAL WELL CONSTRUCTION RECORD IEIi;ff:3sion Pr, -- 4f i
n0 Unit
�g North Carolina Department of Environment and Natural Resources-Division of Water Quality Ss-c ;
.�QL—V 2780 t)�J 10107n WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: f. DISINFECTION:Type AtH Amount 75
KEITH PRESNELL
g. WATER ZONES(depth): i
Well Contractor((In�d-ii�vidual Name From 220 To 221 From 305 T0307
Dev'VEY Individual
VVELL&PUMP CO., INC.
From TO From To
Well Contractor Company Name From To From To
P.O.BOX 308
STREET ADDRESS 6.CASING: Thickness/
BOONE NC 28607 Depth Diameter Wei ht Material
From 0 To 38 Ft: 61/8 .358 PVC
City or Town State Zip Code From To Ft.
26 2651 From To Ft`.
Area code-Phone number
Method
2.WELL INFORMATION: 7.GR From 0 Toth 20 Ft.BENfOI= CwmityFlow
SITE WELL ID#(if applicable) From TO Ft:' — - -- - -
STATE WELL PERMIT#pf applicable) 357574 From To Ft.
DWQ or OTHER PERMIT#(if applicable) &SCREEN: Depth Diameter Slot Size Material
WELL USE AP�Check I'��pkj� )x: Residential Water SupplyFrom To Ft. in. in.
(
DATE DRILLED YY From To Ft. in. in.
TIME COMPLETED AM❑ PMLJ" From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
BANNS EIS ��� Depth Size Material
CITY: COUNTY From To Ft.
LOT 21 MONT EAGLE OFF GREAT SKY DR OFF SHA 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 25 DIRT/CLAY
36.197621 May be in degrees, 25 190 GRANITE
LATITUDE 3 minutes,seconds or
LONGITUDE in a decimal format 190 220 QUARTZ MIX
Latitude/longitude source: M GPS ❑Topographic map 220 221.- CREVICE.
(location of well must be shown on a USGS topo map and 221 305 BLUE GRANITE
attached to this form if not using GPS) 305: 307 CREVICE.
4.WELL OWNER 307 420 GRANITE.
OWNER'S NAME GABPJM KISH
STRE ADDRES RIDGEWOOD CIRCLE,
T�hOUESTA
FL 3P&-
City or Town State Zip Code
(5( 61) ) 402-3786-
Area code-Phone number
5.WELL DETAILS: 11.REMARKS:
420 1 GPM 220-221 '9 GPM 305-307
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES 0 NOKI
40
O. 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 CONSTRUCPqN STANDARDS,AND THAT A COPY OF THIS/
REC AS,BEEN R IDED O E WELL OWNER. G/3U
d. TOP OF CASING IS 1 FT.Above Land Surface* ` O
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C.0118 GNATURE OF TIFIED,WELL CONTRACTOR DATE
e. YIELD(gpm): 10 METHOD OF TEST Air KEITH PRESNELL
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days.Attn:Informations Mgt., Form GW-1 a
1617 Mail Service Center- Raleigh,NC 27699-1617 Phone No.[phone] ext 569. Rev.7/05
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