GW1-2022-02827_Well Construction - GW1_20220224

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RESIDENTIAL WELL CONSTRUCTION RECORD
�C North Carolina Department of Environment and Natural Resources-Division of Water Quality
2780 j 210241
WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: If. DISINFECTION:Type IHTH Amount 0
KEITH PRESNELL
g. WATER ZONES(depth):
Well C ntr�r In v�dual�arn LL &PUMP CO., INC. From HOLE To From To
L7t CAN V From To From TO
Well Contractor Company Name From To From To
P.O.SOX 308
STREET ADDRESS 6.CASING: Thickness/
BOONS NC 28607 0 Depth 140 D'1 O -Material er Isight
From To Ft. b 1 PVC
City or Town State Zip Code From To Ft.
( 828 ) 264-2651 From To Ft.
Area code-Phone number I
Material—
2.WELL INFORMATION: 7 GRromT ODToth 20 F1 B U GrSvirywaw
— _ - --
SITE WELL ID#(if applicable) From TO Ft.
STATE WELL PERMIT#(if applicable) From To Ft.
DWQ or OTHER PERMIT#(•rfapplicable) &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Ap I'rtJb12 ox): Residential Water Supply From To Ft. in. in.
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DATE DRILLED 03.00 From To Ft. in. in.
TIME COMPLETED AM❑ PM From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
DRY HOLE ytg Depth Size Material
CITY: COUNTY From _To Ft.
OFF COVE HARBOR OFF VJ=AMS FARM RD OFF 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) 0 130 DIRT
36.112856 May to s degrees, GRANITE
LATITUDE 3 minutes,seconds or 130
LONGITUDE in a decimal format 180 208 SHALE
Latitude/longitude source: Uxy GPS ❑Topographic map 208 295 GRANITE
(location of well must be shown on a USGS topo map and 295 298 QUARTZ
attached to this form if not using GPS) 298 360 GRANITE
4.WELL OWNER0 SHALE
OWNER'S NAMEAARON&TAMARA =OTT 3% 510 SHALE
70177YT- 510 NO GRANITE
STR
a
City or Town State Zip Code 690 720 SHALE
(9( 15) ) 637-M3
Area code-Phone number
5.WELL DETAILS: 11
805 bR;� Y HOLE- 4r" tTt° t"Pr� -1-' I i
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOYD
c. WATER LEVEL Below Top of Casing: 805 FT. 100 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
R O D HAS BEEN PROVID O THE WELL OWNER.
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 SIGNATURE OF CERTIFIED WELL CONTRATTOR DATE
e. YIELD(gpm): 0 METHOD OF TEST Au KEITH PRESNELL
PRINTED NAME OF PERSON CONSTRUCTING 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 5 68J Rev.7/05
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