GW1-2022-06659_Well Construction - GW1_20220708

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RESIDENTIAL WELL CONSTRUCTION RECORD
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cQ North Carolina Department of Environment and Natural Resources-Division of Water Quality
2780 ' 210188
WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: HTH 22
KEITH PREBNELL f. DISINFECTION:Type Amount
g. WATER ZONES(depth):
Well Contractor(Individual Name 117 1 1; 128 129
DEMY VVRIGH T VVELL &PUMP CO., INC. From To From To
From To From To
Well Contractor Company Name From To From To
STREET ADDRESS P. O.BOX 308 6.CASING: Thickness/
BOONE NC 286T Depth Diameter Weight Material
From 0 To 100 Ft. 61/8 .350 PVC
City or Town State Zip Code From To Ft.
( 829 ) 264-2651 From To Ft.
Area code-Phone number 7.GROUT: Depth Material Method
-From-- _
2.WELL INFORMATION: 0 TO 20 'Ft.BENTON1T— GravitYFlow
— — _ - - _ —----- -- __ --—---
SITE WELL ID#(if applicable) From To Ft S
STATE WELL PERMIT#(if applicable) From To Ft.
DWO or OTHER PERMIT#pf applicable) S.SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply From To 6J2012022 Ft. in. in.
DATE DRILLED From To �Ft. in. in.
TIME COMPLETED 0 '00 AM❑ PM CJ From To Ft. in. in.
9.SAND/GRAVEL PACK:
3.WELL LOCATION:
$ FT K ��� Depth � Size Material
CITY: COUNTY From _To Ft.
5085 ANDY HICKS RD OFF ANDY HICKS RD OFF W From TO Ft. %' 'd k°j fg-
9_
-�
From To Ft. ° ° —
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code)
JUL 0 S 2022
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
❑Slope ❑Valley ❑Flat ❑Ridge ❑Other From To Li„if
(check appropriate box) 0 89 DIRT ,rji,?'QT4 OG
May be in degrees,
LATITUDE 3 36.212506 minutes,seconds or 89 117 GRANITE
LONGITUDE - in a decimal format 117 118 VOID
Latitude/longitude source: 21 GPS ElTopographic map 118 128 GRANITE-RED
(location of well must be shown on a USGS topo map and 12$ 129 VOID
attached to this form if not using GPS) 129 145 GRANITE
4.WELL OWNER
OWNER'S NAMEJ'NS&ROSM HICKS
- -STREET ADDRESSS 085 ANDY-HICKS RD,
BANNER ELK NC 28604
City or Town State Zip Code
( (8= )_963-5784
Area code-Phone number
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 145 10 GPM 117-118 20 GPM 128- 129
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO)U
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c. WATER LEVEL Below Top of Casing: 40 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
RECQaD HAS BEEN PROVIDED T WELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land Surface* 6�1 rJ., / �©
*Top of casing terminated at/or below land surface may require I0 Za�&
a variance in accordance with 15A NCAC 2C.0118 SIGNATURE OF CERTIFIED WELL CON OR DATE
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e. YIELD(gpm): 30 METHOD OF TEST Air KEI I H 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-1a
1617 Mail Service Center-Raleigh, NC 27699-1617 Phone No. [phone] ext 568. Rev.7/05
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