GW1-2022-03395_Well Construction - GW1_20220315

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ELL CONSTRUCTION RECORD
RESIDENTIAL W
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: HTH 55
KEITH PRESNELL f. DISINFECTION:Type Amount
g. WATER ZONES(depth):
Well(iUE p`�V VIiG'IlTWELL &PUMP CO., 1NC. From To 440 440440 Tom$
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 Weight Material
From To Ft.
City or Town State Zip Code From To Ft.
( 8n ) 264-2651 From To Ft.
Area code-Phone number 7.GROUT: Depth Material Method
2.WELL INFORMATION: From To Ft. Grayiw Flow
SITE WELL ID#(if applicable) From To Ft.
STATE WELL PERMIT#(f applicable) From To Ft.
DWQ or OTHER PERMIT#pf applicable) &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply From To Ft. in. in.
2123/2022
DATE DRILLED From To Ft. in. in.
TIME COMPLETED AM ElPM6 From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
DRII.LDEEPER WATAUGA Depth Size Material
CITY: COUNTY From To Ft.
334 RIVERS CREST RD RIVER CREST SUBDIVISON 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) 0 440 EXISTING WELL
36.430"N May o in degrees, 440 468 GRANITE
LATITUDE . 3 minutes,seconds or
LONGITUDE —UT•j in a decimal format
Latitude/longitude source: 1�GPS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4.WELLOWNER
OWNER'S NAMELY IMTG
STREET BRADEX TO FL , 34203 _ MAR 16
2022
City or Town State Zip Code
�t`�aaw�:t 0�;�a
(941) 720-4226 "L. ` ' 1 t
Area-code/-Phone number
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 468 25 GPM 0-440 25 GPM 440-4&
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOS]
c. WATER LEVEL Below Top of Casing: 200 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 BEEN PROVIDED TQMr4WELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land Surface*
'Top of casing terminated at/or below land surface may require (Jo2
a variance in accordance with 15A NCAC 2C.0118 SIGNATURE OF CERTI IED WELL CONTRACTOR DATE
e. YIELD(gpm): 50 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:Information Mgt., Form GW-1 a
1617 Mail Service Center- Raleigh,NC 27699-1617 Phone No.[phone] ext 568. Rev.7/05