GW1-2022-08679_Well Construction - GW1_20220419

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RESIDENTIAL WELL CONSTRUCTION RECORD
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�C North Carolina Department of Environment and Natural Resources-Division of Water Quality
2780 210060
WELL CONTRACTOR CERTIFICATION#
1.WEL ELL f. DISINFECTION:Type HTH Amount 108
g. WATERIJPNESI(�gpth):
Well bt qV(MINI aMLL &PUMP CO., INC. From To From To
From To From To
Well Contractor Company
V.8ftOX 308 From To From To
STREET ADDRESS 6.CASING: Thickness/
BOONS NC 2$60rj Depth Diameter Weight Material
From To Ft. 0 iM 33d tests
City or Town State Zip Code From To Ft.
( 828 )_264-2651 From To Ft.
Area code-Phone number
2.WELL INFORMATION: 7.GROUT: Depth Material Method
From 0 To 20 Ft.BENrONIT Gravity Flow
__ 4
SITE WELL ID#(if applicable) From To Ft. .22 BAGS
STATE WELL PERMIT#(if applicable) From To Ft.
DWO 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.
DATE DRILLED 3/25/2022 From To Ft. in. in.
TIME COMPLETED AM❑ PM From To Ft.- in. in.
9.SAND/GRAVEL PACK:
3.WELL LOCATION:
BANNER ELK Wsta�la Depth Size Material
CITY: COUNTY From To Ft.
OFF DE=BA.R=RD OFF BROADSTONE OFF 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 31 DIRT
May be in degrees,
LATITUDE 3 36;12.814 minutes,seconds or 31 158 GRANITE
LONGITUDE09T+45.525in a decimal format 168 174 QUARTZ
Latitude/longitude source: SGPS ❑Topographic map 174 360 GRANITE
(location of well must be shown on a USGS topo map and 360 470 SHALE
attached to this form if not using GPS) 470 6W GRANITE
4.WELL OWNER - •� 1r"n
OWNER'S NAMEAARON PE ELM L_
STREW DDDRE S1413 HARVEY 1OHNSON RD, �3 -APR �c0
City or Town State Zip Code Inform Prccw, U
nk
(9( 19) ) 604-2665 OQ
Area code-Phone number
5.WELL DETAILS: 11.REMARKS:
a. TOTAL DEPTH: 6W 0.5 GPM 168- 174
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOLt]
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c. WATER LEVEL Below Top of Casing: $0 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
F,�N PR VI D TO T LL OWNER.
d. TOP OF CASING IS 1 FT Above Land Surface* RECO HAS B!/Surface* � �
*Top of casing terminated at/or below land surface may require4
a variance in accordance with 15A NCAC 2C.0118 SIGNATURE OF CEP IFIED WELL CONTRACT R E
0.5 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-1 a
1617 Mail Service Center-Raleigh, NC 27699-1617 Phone No. [phone] ext 568. Rev.7/05
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