GW1--04132_Well Construction - GW1_20240717

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.r. 4" RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina I)eparlmcnt of I:nV Ironment and Natural Resources- Division of Water Quality
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WELL CONTRACTOR CERTIFICATION# 3489 240091
1.WELL CONTRACTOR: f. DISINFECTION:Type NTH Amount 107
RICKY HUFFMAN g. WATER ZONES(depth):
Well Contractor(Individual)Name
From 185 To 220 From 390 To 440
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/
Depth Diameter Weight Material
BOONE NC 28607 From D To 78 Ft. A 1/8 35n PVC
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. 19 BAGS
WELL CONSTRUCTION PERMIT#215924 From To Ft.
OTHER ASSOCIATED PERMIT#(if applicable)
9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply X From To Ft. in. in.
DATE DRILLED 7/1/2024 From To Ft. in. in.
TIME COMPLETED 03:00 AM PM X From To Ft. in. in.
4.WELL LOCATION: 10.SAND/GRAVEL PACK:
CITY: BANNER ELK COUNTY AVERY Depth Size Material
From To Ft.
LOT#47 HEADWATERS OFF FALL CREEK PARKW From To Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) From To Ft.
TOPOGRAPHIC/LAND SETTING:
Slope Valley Flat Ridge Other
(check appropriate box) 11. DRILLING LOG
May be in degrees. From To Formation Description
LATITUDE _ — 36.19906N minutes,seconds or 0 26 DIRT
LONGITUDE 81.94722W in a decimal format 26 70 BROWN SHFI I
— — 70 185 GRANITE
Latitude/longitude source: X GPS Topographic map 185 220 PINK GRANITE
(location of well must be shown on a USGS topo map and 220 390 GRANITE
attached to this form if not using GPS) 390 440 GRANITE QUARTZ MIX
5.WELL OWNER 440 560 GRANITE
560 600 RED GRANITE MIX
OWNER'S NAME KAREN GELLER C/O TIMBER BLOCI _
STREET ADDRESS 3708 CURLEYS FISH CAMP RD __ . -�1�E g
CONNELLY SPRII NC 28612 ��T�* �
City or Town State Zip Code JUL 1 r! 2024
( 866 )- 929-5647
Area code- Phone number 12. REMARKS: Infe:rr f+z '',.-/-4 es:,e.g'Ji
1- GPM 185-220 M"..u#'.:.
6.WELL DETAILS: 2 GPM 390-440
a. TOTAL DEPTH: 600
b. DOES WELL REPLACE EXISTING WELL? YES NOX I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15.A NCAC 2C,WELL CONSTRUCTION STANDARDS.AND THAT A COPY OF THIS
c. WATER LEVEL Below Top of Casing: 90 FT. RECORD HAS BEEN PROVIDED 0 THE WELL OWNER.
(Use"+"if Above Top of Casing)
d. TOP OF CASING IS 1 FT.Above Land Surface* /y
`Top of casing terminated at/or below land surface may require SIGNATUR OF CER I IED WELL CONTRACTOR DATE
a variance in accordance with 15A NCAC 2C.0118. RICKY HUFFMAN
e. YIELD(gpm): 3 METHOD OF TEST AIR PRINTED NAME OF PERSON CONSTRUCTING THE WELL
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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