GW1-2022-03849_Well Construction - GW1_20220331

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.: RESIDENTIAL WELL CONSTRUCTION RECORD
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North Carolina Department of Environment and Natural Resources-Division of Water Quality
2780 ( 210184
WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: f. DISINFECTION:Type 'HTH Amount 36
KEITH PRESNELL
g. WATER ZONES(depth)::
Well Contractor. Indiu.idual blame) From 202 To 203 From To
ULVVtY IUH I VW_LL &F'Ulb H LU., INL.
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 0 To 90 Ft. 61/8 .350 PVC
City or Town State Zip Code From To Ft.
( 828 ) 264-2651 From To Ft.
Area code-Phone number 7.GROUT- Depth Material Method
2.WELL INFORMATION: From 0 To 20 Ft.BENTONTT Gravity Flow
-- — '�4-BAGS-- —--
--- -SITE WELL ID#(if eppiicable) - _ --- - --___.__--_ __"--_ _ . -- From -To— Ft.
STATE WELL PERMIT#(if applicable) From TO Ft.
DWQ or OTHER PERMIT#(if applicable) &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Ap3 licablle Box): Residential Water Supply From—TO—To Ft. in. in.
l24/2
DATE DRILLED yy From To Ft. in. in.
TIME COMPLETED AM❑ PM L'I From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
Depth Size Material
CITY. LINV 7.Fi_ COUNTY AVERY From To Ft.
60 HF.NI EY LN OFF HENLEY OFF HWY 221 OFF HW From _To Ft.
From _To Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
❑Slope ❑Valley 0 Flat ❑Ridge ❑Other From To Formation Description
(check appropriate box) 0 80 DIRT
May be in degrees,
LATITUDE 3 36.0692 minutes,seconds or 80 90 BLUE GRANITE
LONGITUDE -81.88524W in a decimal format 90 202 SWE/GRAY GRANITE
Latitude/longitude source: XGPS ❑Topographic map 202 203 QUARTZ/CREVICE
(location of well must be shown on a USGS topo map and 203 225 DARK BLUE GRANITE
attached to this form if not using GPS)
4.WELL OWNER
OWNER'S NAMEDAVM HOOVER
STREET ADDRESSP BOX 1061 ,
LINVIT 7 F NC 2W46 �n��
City or Town State Zip Code MAR 31
l(704) )-301-8023 Area code-Phone number
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 225 30 GPM 202-203
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOX1
c. WATER LEVEL Below Top of Casing: 50 FT, I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
(Use"+"if Above Top of Casing) 15A NCAC 2C,WELL CONSTRUCTION STANDA,5PS,AND THAT A COPY OF THIS
R R A BEEN P VID TO THE WEWOYVNER.
d. TOP OF CASING IS 1 FT.Above Land Surface*
*Top of casing terminated at/or below land surface may require A/0
a variance in accordance with 15A NCAC 2C.0118 SIGNATURE OF CERTIFrEDWELL CONTRALTOME
e. YIELD(gpm): 30 METHOD OF TEST Air 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�8 Rev.7/05

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