GW1-2022-03724_Well Construction - GW1_20220330

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RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
•m�aM„;,• 2780 210131
WELL CONTRACTOR CERTIFICATION#
1.WEL�f Q(�T,FjQ46
t-KESfV HELL f. DISINFECTION:Type HTH Amount
Pt tt g. WATER?7$NESIg pth)i
Well(3 %V(r ' +ZA fI LL &PUMP CO., INC:. From To From To
From To From To
Well Contractor Company fjlatlt.BOX
30$ From To From To
STREET ADDRESS P.
U.
6.CASING: Thickness/
BOONE KC 28607 0 Depth Dlimeter je�l�ht �tlaterial
From To 40 Ft. 1/8 PVG
82�Ity oL TOw-�651 State Zip Code From To Ft.
Zfr4
( )- From To Ft.
Area code-Phone number
7.GROUT: Depth Material Method
2.WELL INFORMATION: From 0 To 20 Ft.BE 4TONIT GravltyFlow
SITE WELL ID#(if applicable) From To Ft.
STATE WELL PERMIT#(if applicable) 332237 From To Ft.
DWQ or OTHER PERMIT#(if applicable) &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Ap I'cab a B2ox): Residential Water Supply From To Ft. in. in.
1$r0
DATE DRILLED yy,, From To Ft. in. in.
TIME COMPLETED AM❑ PM 6 From To Ft.
in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
Depth Size Material
CITY.. FLEETWOOD COUNTY ASHE From To Ft.
OFF MERIVMMS HM=E FARMS RD OFF BIG FL From TO Ft.
From To Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
❑Slope ❑Valley ❑Flat ❑Ridge ❑Other From To Formation Description
(check appropriate box) 0 30 DIRT
36.310107 May be in degrees, 30 190 GRANITE
LATITUDE 3 minutes,seconds or
LONGITUDE -2=. 157 in a decimal format 190 198 SHALE
Latitude/longitude source: IN GPS ❑Topographic map 198 270 GRANITE
(location of well must be shown on a USGS topo map and 270 271 VOID
attached to this form if not using GPS) 271 205 GRANITE/QUARTZ MI)
4.WELL OWNER 285 305 GRANITE
OWNER'S NAMES&» WINTER
STREET ADDRESSI 908 CINDY-CT-, _.
BURLESON TX 76028
City or Town State Zip Code
($( 17) )-909-925$ " "'[
Area code-Phone number
5.WELL DETAILS: 11.REMARKS: MAR 3 0 202?
a. TOTAL DEPTH: 305 8 GPM 270-271
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOXI WIX
.;WI , FP
c. WATER LEVEL Below Top of Casing: 84 FT. I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
(Use"+"if Above Top of Casing) 15A NCAC 2C,WELL CONSTRUCTION STAND DS,AND THAT A COPY OF THIS
REQQBQ HAS BE N PR ID OTHEW§"NVNER.
d. TOP OF CASING IS 1 FT.Above Land Surface*
Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C.0118 IGNAT E F ER IFIE W LL CO O
e. YIELD(gpm): $ 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-1a
1617 Mail Service Center-Raleigh,NC 27699-1617 Phone No.[phone] ext 566.! Rev.7/05

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