GW1-2022-08676_Well Construction - GW1_20220428

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RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 2780 E 21
1.WELL CONTRACTOR:
f. DISINFECTION:Type H.TH Amount 23
KEITH PRESINELL g. WATER ZONES(depth):
Well Contractor(Individual Name) From From 13 To 132
DEVVEY VAIGH T WELL &PUMP CO., MC. From To From To
Well Contractor Company Name From To From To
STREET ADDRESS U n R03C 3(1R 6.CASING: Thickness/
Depth Diameter Weight Material
BOONE NC 28607 From r To a5 Ft. 6 t_J8 _I_r'ro IM4(7
City or Town State Zip Code From To Ft.
( M )-264-2651 From To Ft.
Area code-Phone number
2.WELL INFORMATION: 7.GROUT: Depth i Material Method
From 0 To20 Ft.$INT0 vity R-1
-SITE-WELL-ID"#jif app icabTe-- -- - - - -' From—'.___-To-- - -- Ft.i g
STATE WELL PERMIT#(if applicable) From To Ft.
DWQ or OTHER PERMIT#(if applicable) &SCREEN: Depth Diameter Slot Size Material
WELL USE(Check Applicable Box): Residential Water Supply U From To Ft. in. in.
DATE DRILLED 4/22A-002 From To Ft. in. in.
TIME COMPLETED Cjj:^^ AM❑ PM l From To Ft. in. in.
9.SAND/GRAVEL PACK:
&WELL LOCATION:
Depth Size Material
CITY: WRST TRFF'RRCON COUNTY AgTM. From _To Ft.
From TO Ft.
OFF BALD MTN RD OFF BUCK MTN RD OFF BUCK 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)
May be in degrees, 0 '• ^'�T
LATITUDE 3 minutes,seconds or IR y TE
LONGITUDE LAI in a decimal format
Latitude/longitude source: Ll GPS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
L 140
4.WELL OWNER
OWNER'S NAME
STREET ADDRESSo�o
State IC Zips
APR 2 S 2029
�cl-R& ber
5.WELL DETAILS: 11.REMARKS: DV 2T�XTM
tit '"".' �')r �•- � !�'�?
a. TOTAL DEPTH: d87--884 '• S v s
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOk❑
c. WATER LEVEL Below Top of Casing: FT. I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
(Use"t"if Above Top of Casing 15A NCAC 2C,WELL CONSTRUCTI N STANDARDS,AND THAT A COPY OF THIS
RECORD HAS BEEN ROVIDED T E WELL OWNER.
d. TOP OF CASING IS FT.Above Land Surface'
Top of casing terminated at/ r below land surface may require Oil
a variance in accordance with 15A NCAC 2C.0118 ftIGNATUAE OF RTIFIEDi L O R DATE
I
e. YIELD(gpm):�0 METHOD OF TEST I
Air
PRIN CONSTRUCTING THE WELL
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Submit the original to the Division of Water Quality within 30 days.Attn:Information 1Mgt., Form GW-1 a
1617 Mail Service Center- Raleigh,NC 27699-1617 Phone No. [phone] ext 5 68! Rev.7/05
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