GW1-2022-06661_Well Construction - GW1_20220708

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RESIDENTIAL WELL CONSTRUCTION RECORD
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North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 2780 220016
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1.WELL CONTRACTOR: :HTH 48
KEITH PRESNELL f. DISINFECTION:Type 0 Amount
g. WATER ZONES(depth):
Well Contractor Individual Name 120 121 278 279
( • —•-• •—• �• • From TO From To
UtVVLY WKIfaH I VVL-LL &PUIVlt' (_;U., INC.
From To From To
Well Contractor Company Name From To From To
STREET ADDRESS P. O.BOX 308 6.CASING: Thickness/
BOONE NC 2MO Depth Diameter Weight Material
From 0 To 38 Ft. 61/8 .350 FVC
City or Town State Zip Code From To Ft.
( 828 ) 264-2651 From To Ft.
—
a code-Phone number
7.GROUT: Depth Material Method
2.WELL_INFORMATI.ON: 0 20 BENTO_NJ Gravity Flow
— _ - -- -- — --To Ft
---From - ---
SITE WELL ID#(if applicable) From To Ft. MAA_G�
STATE WELL PERMIT#(if applicable) From TO Ft j
DWQ or OTHER PERMIT#(if applicable) 8.SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply From To Ft. in. in.
6/15/2022
DATE DRILLED From To Ft. in. in.
TIME COMPLETED AM❑ PM 6 From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
Bp�jj�.j�FT K '��� Depth Size Material
CITY: COUNTY From To—,,Ft.
—
LOT 69 MONTEAGLE OFF F030M DR OFF GREAT From TO Ft.
From _To Ft. -=F� y�
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) s : L
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG JUL 0 8 2022
❑Slope ❑Valley ❑Flat ❑Ridge ❑Other From TO Formation Description
(check appropriate box) 0 24 DIRT Ini3iri,3«i1 --'.'g Line,
May be in degrees,
LATITUDE 3 36.19222N minutes,seconds or 24 120 GRANITE
LONGITUDE 81.$Q432W in a decimal format 120 121 VOID
Latitude/longitude source: S GPS ❑Topographic map 121 202 GRANITE
(location of well must be shown on a USGS topo map and 202 210 SHALE
attached to this form if not using GPS) 210 278 GRANITE
4.WELL OWNER 278 279 VOID
OWNER'S NAMESrEVE LUE= 279 300 GRANITE
%FREDERICK BUILDING GROUP 2340-B
STREET ADDRESS
BANNER ELK NC 28604
City or Town State Zip Code
( (704) )_650-5372
Area code-Phone number
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 300 5 GPM 120- 121 10 GPM 278-279
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOXI
c. WATER LEVEL Below Top of Casing: 60 —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
$E (RHAS BEE P VIDE O;THE WELL OWNERJ'11h—
d. TOP OF CASING IS ' FT.Above Land Surface'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C.0118 SIGNATURE OF TIFIED ELL CONTRA R DATE
e. YIELD(gpm): 15 METHOD OF TEST Air KEITH PRESNE L
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,NC 27699-1617 Phone No.[phone] ext 56 8. Rev.7/05
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