GW1-2022-03855_Well Construction - GW1_20220331

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RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 2780 200206-I
1.WELL CONTRACTOR: f. DISINFECTION:Type IHTH Amount 109
KEITH PRESNELL
g. WATER ZONES(depth):
Well Contractor(Individual Name) From 55 To 56 From To
DtWEY YYh GH T WELL &PUMP CO., INC. From To 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 23 Ft. 61/8 .350 PVC
City or Town State Zip Code From To Ft.
( 828 )-264-2651 From To Ft.
Area code-Phone number
2.WELL INFORMATION: 7.GROUT Depth Material Method
- —^ -- - __ ____
From 0 To 20 Ft.BENTONIT Gravity Flow
SITE WELL ID#(if applicable) -_—From -To Ft-2 —
STATE WELL PERMIT#(dapplicable) From To Ft.
DWQ or OTHER PERMIT#(dapplicable) 183941 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply N From To Ft. in. in.
DATE DRILLED 3/3/2022 From To Ft. in. in.
TIME COMPLETED 03:00 AM❑ PM I From To Ft. in. in.
9.SAND/GRAVEL PACK:
3.WELL LOCATION:
Depth Size Material
CITY: BOONE COUNTY Wat8= From To Ft.
LOT 7 HORIZON WAY OFF WOODLAND SPRINGS O 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 15 DIRT
May be in degrees,
LATITUDE 3 minutes,seconds or 15 5S GRAY GRANITE
LONGITUDE in a decimal format 55 56 CREVICE
Latitude/longitude source: CXGPS ❑Topographic map 56 SIM GRAY rRANITF
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4.WELL OWNER
OWNER'S NAMEPAUL HOSLIANN
STREET ADDRESSI9816 SHEARW-ATER PT DR:
CORNELIUS NC 28M I
City or Town State Zip Code OR a
(( 954) )-224-5089
Area code-Phone number '
r: _ -
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 605 4 GPM 55-56
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOJI
c. WATER LEVEL Below Top of Casing: 75 FT. I DO HEREBY CERTIFY THAT THIS WELL WAS CO STRUCTED IN ACCORDANCE WITH
(Use"+"if Above Top of Casing) 15A NCAC 2C,WELL CO TRUC ON STAND D AND THAT A COPY OF THIS
REC A BEEN PRO THE WE OW ER.
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 SIG AT OF ERTfFIE L CONTRA OR DAT
e. YIELD(gpm): 4 METHOD OF TEST Air KEITH PRFPNPI if
PRINTED NAME OF PERSOWCONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days.Attn: InformationiMgt., Form GW-1a
1617 Mail Service Center-Raleigh, NC 27699-1617 Phone No.[phone] ext 568. Rev.7/05

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