GW1-2022-04839_Well Construction - GW1_20220520

RESIDENTIAL WELL CONSTRUCTION RECORD
�co North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: f. DISINFECTION:Type_H T N Amount _
KE171-1 F R ESN ELL g. WATER ZONES(depth):
Well Contractor(Individual Name) From 222 To 223 From 720 To 721
DEWE-Y',ViV 1:G (- T 'WELL &FUNJP CO., INC..
From To _ From To
Well Contractor Company Name From To From To
U. O.EO 30�
STREET ADDRESS 6.CASING: Thickness/
BOOT NC 22607 Depth Diameter Weight Material
L From 0 To 66 Ft. 6 1/8 .350 PVC
City or Town State Zip Code From To Ft.
( 22 )-2 =1 From To Ft.
Area code-Phone number
7.GROUT: Depth Material Method
2.WELL INFORMATION: From 0 To 20 Ft.EI~NITON T _ Gr ayity F'1ow
SITE WELL ID#(if applicable) From To Ft.'14 E CIDS
STATE WELL PERMIT#(if applicable) From To Ft.
DWQ or OTHER PERMIT#(if applicable) 10591 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply Q From To Ft. in. in.
DATE DRILLED 5.G'2.120122 From To Ft. in. in.
TIME COMPLETED 03:C* AM❑ PM M From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
Depth Size Material
CITY: ,AMTEEIR EtiK COUNTY ANTE'—RY From To Ft.
LOT G-40 30 VA,LTT VITATC'I•-i(_T OITLO:IDGE W00 From _To t.
From To Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SEl HNG: 10.DRILLING LOG
❑Slope ❑Valley ❑Flat ❑Ridge ❑Other From To Formation Description
(check appropriate box) n FA r1I R—
May be in degrees, —
LATITUDE 3 36.180674 minutes,seconds or 5ti J70 _ t'RAY f'RAIiITF
LONGITUDE -21.96571 in a decimal format 222 223 5�!,,,r1AI I r F111C'F
Latitude/longitude source: CI' GPS ❑Topographic map 22.3 72Q — Ili'HTt,FAYPRA.MITF
(location of well must be shown on a USGS topo map and 720 721 _ CRRlIesE
attached to this form if not using GPS) 721 805 EI_I_JE r;RAN ITE
4.WELL OWNER -
OWNER'S NAMENIATT C0111SKEY
STREET ADDRESS%TOM ZOGERS CONSTRUC-TION 9R72?iTh Y _ S"�a�-5 �a m bn'
ij
1 '_R6CC.4
City or Town State Zip Code _ MAY 2 0 2022
(( 1(7) )- 544-91u8
Area code-Phone number
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: C); n 7 Ge o7„i 't:o_ 'c r= .r2C�a 21
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOQ T
c. WATER LEVEL Below Top of Casing: -C 1 F; I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
(Use"+"if Above Top of Casing) 15A NCAC 2C,WELL CONSTRU IOIJ STANDARDS,AND THAT A COPY OF THIS
RECORD HAS BE PROVIDE T THE WELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land Surface' O'�4) � I
Top of casing terminated at/or below land surface may require 5-17'
a variance in accordance with 15A NCAC 2C.0118 SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): G METHOD OF TEST Air 14 c1 7 W Qo9cN1�I I
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, INC 27699-1617 Phone No. [phone] ext 568. Rev.7/05

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