GW1--04971_Well Construction - GW1_20240816

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3 RESIDENTIAL WELL CONSTRUCTION RECORD
I�' Department,'-( 1. ,?_,I North Carolina of Environment and Natural Resources- I)i‘ision of Water Qualit,
'' n"' WELL CONTRACTOR CERTIFICATION# 3489 230106
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 0
RICKY HUFFMAN g. WATER ZONES(depth):
Well Contractor(Individual)Name From DRY HC To From To
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 0 To 28 _Ft. 8 1/8 350 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
SITE WELL ID#(if applicably:) From 0 To 20 _._Ft._BENTONIT GRAVITY
-- — From_ To Ft 30 BAGS
WELL CONSTRUCTION PERMIT#375883 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 07/12/2024 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 WATAUGA Depth Size Material
From To Ft.
OFF CUCUMBER TREE OFF CLOUDRISE OFF BR' From To _Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) From To Ft.
TOPOGRAPHIC/LAND SETTING:
Slope Valley X Flat Ridge Other
(check appropriate box) 11. DRILLING LOG
May be in degrees. From To Formation Description
LATITUDE 36.188055 minutes,seconds or 0 15 DIRT
LONGITUDE 81,752866 in a decimal format 15 210 GRANITE
— — 210 248 SHELL
Latitude/longitude source: X GPS Topographic map 248 380 GRANITE
(location of well must be shown on a USGS topo map and 380 450 GREEN GRANITE MIX
attached to this form if not using GPS) 450 465 SHELL
5.WELL OWNER 465 820 GRANITE
OWNER'S NAME RAYDEL LORENZO r,.. ,"
STREET ADDRESS 6495 W 10TH AVE
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HILEAH FL 33012 AUG I tz 2024
City or Town State Zip Code ^^ f
( 305 )_ 244-5796 tr,�....•.,;.G^' ` y
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Area code- Phone number 12. REMARKS:
DRY HOLE
6.WELL DETAILS:
a. TOTAL DEPTH: 820
b. DOES WELL REPLACE EXISTING WELL? YES 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: 820 FT. RECORD HAS BEEN PROVIDED T THE WELL OWNER.
(Use"+"if Above Top of Casing) J����?(�
d. TOP OF CASING IS 1 FT.Above Land Surface' -� •`^'
*Top of casing terminated at/or below land surface may require SIGNATU E OF CE I I DE WELL CONTRACTOR DATE
a variance in accordance with 15A NCAC 2C.0118. RICKY HUFFMAN
e. YIELD(gpm): 0 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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