GW1--07247_Well Construction - GW1_20231108

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r RESIDENTIAL WELL CONSTRUCTION RECORD
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5��( �r' g North Carolina Department of Environment and Natural Resources-Division of'Water Quality
',Z ^,,'. WELL CONTRACTOR CERTIFICATION# 3489 230,070
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 35
RICKY HUFFMAN g. WATER ZONES(depth):
Well Contractor(Individual)Name From 80 To 120 From 120 To 145
DEWEY WRIGHT WELL&PUMP CO., INC From To From To
Well Contractor Company Name From To From To
STREET ADDRESS PO BOX 308 7. CASING: Thickness/
BOONE NC 28607 From 0 Depth
To 78 Ft. 611/8ter Weight Material
City or Town State Zip Code From To Ft.
(828 )_264-2651 From To Ft.
Area code- Phone number
2.WELL INFORMATION: 8. GROUT: Depth Material Method
From 0 To 20 Ft. BENTONIT GRAVITY
SITE WELL ID#(if applicable) • From To Ft. 20 BAGS
WELL CONSTRUCTION PERMIT# 147290 From To Ft.
OTHER ASSOCIATED PERMIT#(if applicable)
9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply ID( From To Ft. in. in.
DATE DRILLED 10/26/2023 From To Ft. in. in.
TIME COMPLETED 03:00 AM 0 PM DX From To Ft. in. in.
4.WELL LOCATION: 10.SAND/GRAVEL PACK:
CITY: JEFFERSON COUNTY ASHE Depth Size Material
From To Ft.
OFF HWY 16 OFF HWY 163 OFF IDLEWILD OFF H\ From To Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) From To Ft.
TOPOGRAPHIC/LAND SETTING:
X Slope 0 Valley 0 Flat 0 Ridge 0 Other
(check appropriate box) 11. DRILLING LOG
May be in degrees, From To Formation Description
LATITUDE — 36.35565N minutes,seconds or 0 18 DIRT
LONGITUDE 81.38637W in a decimal format 18 80 GRANITF
— — 80 120 GRANITE QUARTZ MIX
Latitude/longitude source: )G GPS o Topographic map 120 145 SHALE
(location of well must be shown on a USGS topo map and 145 170 GRANITE
attached to this form if not using GPS) 170 172 BROWN SHALE
172 185 GRANITE
5.WELL OWNER I
OWNER'S NAME DANIEL MILLER
STREET ADDRESS 6520 NC HWY 16S
JEFFERSON NC 28640
City or Town State Zip Code t �^" •:. '." v
( 336 )- 977-9550 NOV r? S 2023
Area code- Phone number 12. REMARKS:
2 GPM 80-120 •n<___ ,: , _..
6.WELL DETAILS: 6 GPM 120 145 y "'•` :7`y I:nt
a. TOTAL DEPTH: 185
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b. DOES WELL REPLACE EXISTING WELL? YES 0 NOX I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
c. WATER LEVEL Below Top of Casing: 20 FT. RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
(Use"+"if Above Top of Casing) 7� �1
d. TOP OF CASING IS 1 FT.Above Land Surface* ! �()J JU �23
*Top of casing terminated at/or below land surface may require SIGNATURE F CERTIFIE' ELL CONTRACTOR DATE
a variance in accordance with 15A NCAC 2C.0118. RICKY HUFFMAN
e. YIELD(gpm): 8 METHOD OF TEST AIR PRINTED NAME OF PERSON CONSTRUCTING THE WELL
i
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt., Form GW-la
1617 Mail Service Center—Raleigh, NC 27699-1617 Phone No. [phone] ext 568. ' Rev.3/07

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