GW1-2022-07079_Well Construction - GW1_20220801

i -
d s�STA1 o
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
2780 =103
WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: HTH 4g
KEITH PRESNELL f. DISINFECTION:Type Amount
g. WATER ZONES(depth):
Well Coptra Y In �uFall�l me LL &PUMP CO., INC. From 263 To 26: ' From To
Qt T From To From To
Well Contractor Company Name From To From To
P. 0.SOX 308
STREET ADDRESS 6.CASING: Thickness/
BOONE NC 22607 Depth. Diameter Wei ht Material
From 0 To 84 Ft. 61/4 .189 GALS'
City or Town State Zip Code From To Ft.
( us ) 264-2651 From To Ft.
Area code-Phone number
7.GROUT- Depth Material Method
-_----- 2.WELL IN-FO-R-M--A—TI-ON: _ . - 0 20 EENTONIT Gravitvew
_ __ From--- T Ft.--
. --
SITE WELL ID#(if applicable) From To Ft.22.16AUS
STATE WELL PERMIT#(if applicable) 6509 From To - Ft.
DWQ or OTHER PERMIT#(if applicable) 1 &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Ap I'cable Box): Residential Water Supply From To Ft. in. in.
&929/2022
DATE DRILLED From To Ft. in. in.
TIME COMPLETED AM❑ PM 1 From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
LAUREL SPRINGS Aj LEGAI.TY Depth Size Material
CITY: COUNTY From To Ft.
11130 NC HWY 18N OFF HWY 18 OFF HWY 82 OFF F From _To Ft.—
From-30— Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING: 10.DRILLING LOG
❑Slope ❑Valley kl Flat ❑Ridge ❑Other From 7TO 2 Formation
ation Description
(check appropriate box)
May be in degrees,
36.425NN 72 120 GR ITE
LATITUDE 3 minutes,seconds or
LONGITUDE � ( in a decimal format 120 196 SHALE
Latitude/longitude source: U GPS ❑Topographic map 196 i
(location of well must be shown on a USGS topo map and u oty
attached to this form if not using GPS) Az 25F— VOID
lt7t)
4.WELL OWNER JA14ES&CELENA AMSURGEY
OWNER'S NAME
STREET ADDRESS/a b.
ENNICE -
City or Town State Zip Code
( (704) 305-4970
Area code-Phone number
5.WELL DETAILS: Il.RE�x
a. TOTAL DEPTH: 305 30 GFM 265 -266 WD1111111111111111111111OR PrOC664ing Unit
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOY]
60
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
1 RECORD HAS BEEN PROVIDE 06i2zi
wl ,, aaae��7-a7q
ELL OWNER.
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 C TIFIED WTEL CONTRACTOR DATE
e. YIELD(gpm): 30 METHOD OF TEST Air KEITH PRESNELL
PRINTED NAME OF PERSON 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

t say' '
tl►
V
_ 3