GW1-2021-02740_Well Construction - GW1_20210811

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RESIDENTIAL WELL CONSTRUCTION RECORD
o 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 143
g. WATER ZONES(depth):
Well Contractor(Individual Name) From 379 To 380 From 540 T0541
DEVVEY 1MRiGH T VVELL&PUMP CO., INC. From 761 To 762 From To
Well Contractor Company Name From To From To
STREET ADDRESS P.O.BOX 308 6.CASING: - Thickness/
BOONE NC 28607 Depth Diameter Weight Material
From 0 To 40 Ft. 61/8 .350 PVC
City or Town State Zip Code From To Ft.
( = )2614-2651 From To Ft.
Area code-Phone number
7.GROUT: Depth Material Method
2.WELL INFORMATION:
.__From 0 To 20 _FtRENTONff Gravity Flow, -- .
SITE WELL ID#(if applicable) From To Ft?28p►GS
STATE WELL PERMIT#(if applicable) From To Ft.
DWQ or OTHER PERMIT#tif applicable) 184919 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water SupplyKI From To Ft. in. in.
DATE DRILLED 7/21/2021 From To Ft. in. in.
TIME COMPLETED 03:00 AM❑ PMXI From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
Depth Size Material
CITY: MONW= COUNTY WatagM From To Ft.
LOT 503 OFF OLD DMIAN IWNO OFFFUGH MOUN 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) n 3n ❑IRT
May be in degrees,
LATITUDE 3 N36#20.817 minutes,seconds or 30 379 RLUF rRANITF
LONGITUDE W081#42.610 in a decimal format 379 380 CREVICE
Latitude/longitude source: W GPS ❑Topographic map 380 5d0 GRAYIBLUE GRANITE
(location of well must be shown on a USGS topo map and Sd0 5df 01 IART71CREVICF
attached to this form if not using GPS) Sdi 761 GREY GRANITE
4.WELL OWNER 751 762 i CREkACF
OWNER'S NAMEIEFR-KINGREE 762 806 DARK GRANITF
- STREET ADDRESS°q TOM-
BANNER ELK NC 22604
City or Town State Zip Code \�
9(( 10) ).-544-9168 r `3`��
Area code-Phone number
5.WELLDETAILS: 11.REMARKS:
a. TOTAL DEPTH: 805 2 GPM 379- 3PO I S C'PM 540-S41
b. DOES WELL REPLACE EXISTING WELL? YES❑ N0)7 1 GNIM.761 -762.
C. WATER LEVEL Below Top of Casing: 51 FT. I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
(Use"+"if Above Top of Casing) 15A NCAC 2C,WELL CONSTRUCTRA4STANDARDS,AND THAT A COPY OF THIS
RECORD HAS BEEN P VIDED TQrrPJE WELL OWNER.
d. TOP OF CASING IS 1. FT.Above Land Surface' i ^/©
"Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C.0118 SIGNATURE OF CERTIFIED WELL CONTRAC DATE
e. YIELD(gpm): 4.5 METHOD OF TEST Air
PRINTED NAME OF PERS CONSTRUCTING
44 THE WELL
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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 5681 % Rev.7/05
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