GW1-2022-04247_Well Construction - GW1_20220428

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RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
2780 210M
WELL CONTRACTOR CERTIFICATION# F ``
1.WELL CONTRACTOR: HTH Ilg
KEITH PRESNELL f. DISINFECTION:Type Amount
g. WATER J?NES&pth):
Well -L tAt—Y(i it"At'a LL Fla PUMP CO.. iN C. From To From To
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 24 Ft, 6118 .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.B=ONIT Oro I ow
SITE WELL 04(if applicable) - -From - --To Ft:t St RA
STATE WELL PERMIT#(if applicable) From To Ft.
i
DWQ or OTHER PERMIT#(If applicable) 1¢St3og &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply From To Ft. in. in.
DATE DRILLED Q2012022 From To Ft. in. in.
TIME COMPLETED 01-0 5 AM❑ PM W From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
Depth Size Material
CITY: JEFFER.SON COUNTY A= From _To Ft.
From TO Ft.
OFF RIVER FRONT DR OFF CLAUDE UkSH OFF HW 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)
May be in degrees, Ell 12 DIRT
LATITUDE 3 minutes,seconds or
in a decimal format
LONGITUDE
Latitude/longitude source: R GPS ❑Topographic map —
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4215 f
4.WELL OWNER
i
OWNER'S NAME 11TGI �rReBy LyO �r<
STREET ADDRESS2
State Zip
(� ) Pall
d�
A e?a c6de-Phoneftber APR 28 20
22
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: W GPM��j
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOk ^'nnr1 ,G?.Iij I�qT
C. WATER LEVEL Below Top of Casing: 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 PR VIDED HE WELL OWNER.
d. TOP OF CASING IS FT.Above Land Surface'
'Top of casing terminated at/ r below land surface may require &DI 7. nn lael 117 A/Al- os�y'7=-?N
a variance in accordance with 15A NCAC 2C.0118 SIGNATURE OF CgfffIFTED WEL R DATE
e. YIELD(gpm): �n METHOD OF TEST _ i
"" PRIN I 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 568. Rev.7/05

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