GW1-2022-08216_Well Construction - GW1_20220505

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::,: RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
' 2790 I 210119
WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: I HTH 106
KEITH PRESNELL f. DISINFECTION:Type Amount
g. WATER ZONES(depth):
Well Contractor(Individual Name) 370 390
DEVYEY VVIRiGH I WELL &F'U(V P CO., INC;. 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 From 0 Deopth 140 Ft. Diameter
i UBer 35uht Material
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.BENTOb= Gravitv Flow
SITE WELL ID#(if applicable) From To Ft.24 �i
-- ---STATE WELL_P-ERMI-T_#(If-applicable) _From___ _—_To______ Ft._ _—
DWO or OTHER PERMIT#(if applicable) &SCREEN: Depth Diameter. Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply From To Ft. in. in.
DATE DRILLED V27/2022 From To Ft. in. in.
TIME COMPLETED 03:QU AM❑ PM From To Ft. in. in.
9.SAND/GRAVEL PACK:
3.WELL LOCATION:
Depth Size Material
CITY: CRUMPlM COUNTY ASHE From _To Ft.
200 FLAT TOP RD OFF HVJY 16 OFF HW 221 OFF H From _To Ft.—
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) 0 129 DIRT
36.451302 May be in degrees, 1 187 GRANITE
LATITUDE 3 minutes,seconds or
LONGITUDE , . 6 in a decimal format 187 230 SHALE
Latitude/longitude source: La GPS Cl Topographic map 230 370 GRANITE
(location of well must be shown on a USGS topo map and 370 3W
attached to this form if not using GPS) 380 510 GR ;"". 1<._.
4.WELL OWNER 510 530 SHALE
OWNER'S NAME VULLIAMDHOUCK 530 605 GRANIT
STREET ADDRES �w�4
CRUMPLFR-__ _ - -
City or Town State Zip Code
(3( 336) 977-9779
Area code-Phone number
5.WELL DETAILS: 605 11. GPM KS: -3$0
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOt
c. WATER LEVEL Below Top of Casing: 100 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 PROVIDED T WELL OWNER.
d. TOP OF CASING IS 1 FT.Above Land Surface*
*Top of casing terminated at/or below land surface may require SIN
/a variance in accordance with 15A NCAC 2C.0118 OF CERTIFIED WELL CONTRACTOR DATE
1 Air KEITH PRESNELL
e. YIELD(gpm): METHOD OF TEST
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, INC 27699-1617 Phone No.[phone] ext 56
Rev.7/05

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