WI0100418_Geothermal Well Construction Record (GW1)_20160420

j t
i� Divi f N 1
I NoaRESIDFIVT 435252
North Cry�Jj)fa� %ia WELL CONSTRUCTION
fEnvuonmpnt and Natural RECORD I LP cc 5
WELL CONTRACTORnt°rOl RE6O°rces'Division ofWeter Quality
CERTIFICATION #
7. WELL ICONTRACT(M Want (X N Rnolmnal Onemtlons r i� _...
n-H i I rnra�
ci:� 1 ��,��,��, Slate Zlp Cotle
Area cado Phone number '--
2. WELL INFORMATION:
WELL CONSTRUCTION PERK#
OTHER ASSOCIATED PERMI -�i3f• FI�—
Ta(IraPWleems)
SITE WELL ID#Ja t PWiaBaj_ � �--
3. WELL USE (Check One Box) Menllod
ngo Industrial/Commercial❑ Agdcultur.10 Recolony 0l/Public❑
IrrigallonE Other Df'(Ilsluee)_6-je,41,4,lnJecgon❑
DATE DRIU ED,_tL L_ 1--
4. WELL LOCATION:
Q
(Sire Neme,�lummmnalN 9andlvleloS�Lpat—)
arv:,l�thev Elk
TOPOGRAPHIC/LAND SETTING: (m.k ppmpdele boa) forSlope ❑Valley ClFIat 0Rldge Clothe,_
LATITUDE 30 _•�/- �_"GMs OR3
LONGITUDC--38J_ �Y X� DO
",,a. 1 MS OR 7X��_�oD
Lalilutledpngllutle source; [vG.;ps �I'opogrephic map
(location of wel/masf be shown on a USGS Ingo maP antle#achadN
this Porn i/nof using GPSJ
5../F�yA����C�ILITY (Name of the�bnsl�nasa whhm, the well Is located.)
L ,1,ty 5�1fIe Sk,-I;Q.VT;,
Fe llily Neme I I '
�,_1:�t_„ I,�� S{ Facility lop (If applicable
Slreel Aetlre'aLs-1-'
CITY Trr'; F -�- %+---"�C 1_
Slate ZIP Code
d. TOPOFCASINGIS
*TOP of maing Impaled apbw. Land Surface.
pr b FT. lentleLUacamay equlre
e vadance lne ce Wlpl iSANCAC2C.011B.
:e. YIELD(Bpm):
METHOD OF TEST
t f. D181NFECTON: Type
'g• WATER ZONES(depth):
Amount
T°p ffo Bottom_
:Tap Bonam Top Bottom__
Top TOP BoBottom3011m, _
Top Bottom_
: T. CASING: Depth Thlohneee/
Top l��p. Diameter Weight Material
-T" Bo[lomn_ Ft._
Top Material
_--__
T°P—_Bmi°m FL_
t B. GROUT: Depth ,�pI
Mal"
Tot ul� Method
P_Q,Botlam L I -Ft. j lur"1`IJ,l
Top— Bottom Ft.
TOPS Bmtom_ FL---
8. SCREEN: Depth pqp,
Top _Bogam eter Sim Size Material
Fl.�
TOP— In.
_ Bonoe_ Ft.
in. _ in
Top_ Bottom_�
_ Ft. —In. ,—_ In. _
To-BAND/GRAVEL PACK: --
Depth
TOP —Bottom Ft. Sim Material
: Tap—Bonam m ---
Top—sothon _Ft.— ----
II, DRILLING LOG
TOP Bottom Formation Oaecdp0on
<Ip Code -
L1'I - too]
; 12. REMARKS:
Area cod, Phone nolnbar _
S. WELL DETAILS:
a. TOTAL DEPTH: If I-) ; 1-HERE I,UIR ryTHAII, WELL Wpg 1W NCpC b. :///3CWELL WNST N8TANppRDS.Al I yHNAMYORMNCEWTHDOE3 WELL RRECORD ENPq °EDTIiW- TAPoPOFTHISEPLACE EXISTING WELL? YES ER, c. WATER I.EVELBDImb Top of Casing: ISIGNATUREOFCERTIFIE'�—
(Usn'v^Pgbove Top of Casing) ---FT' WELT CONTRAL' R DATE t�
PR�L�NN3TRUCTI�-' N�THE WELT.
nubndt Wjthin 30.days of DGmplgt[on to: D VIBIOn bf Water quailty •InfoflnetlOn PrOCea61n®, Form GW-lb
'1617 flail Mervite Center; Raleigh, NC 27698.11, Phone: [phone]
'

DilufMIWIli suun;ps
�^ N 4EMS_1 VA
"� > ¢f 1JorlhI�na A¢a
ofEavirol
WELL CO
1. WEL,GGL CON N'f'RACCOR CER7
1 I TRgCTC� afer OnR al1ty op:onal Operations
1
C
T- >l State ZIP Code
Area code Phone"4 ='L
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# IDS uI VC) 'it
OTHER ASSOCIATED PERMIT#(irapplicable)
SITE WELL ID N(It d,pI(.Ne)_ —_
3. WELL USE (Chase One BOx)MOnitodng❑ Munlcipel/Public❑
Intlusidai/COmmercl.1 ggdc Onnor
Itteal , Recove
Irrigatiohp Other ry❑ 111160lon❑
(,)at
DATE DRILLED
A. WELL LOCATION:
it
(StreetN me -,I an, c '-`"—�'f F
} mvnry 3 btllW i L tNa
ClTY: JY� Pe4, ,hp Code)
TOPOGRAPHIC S SETTING (b cOe NTY of r
OBlope ❑valley ❑Flat pPrePrieie Opx)
LATITUDE 33 0Rnidge� Miner
IONGIFUOEDMS OR 33x.xX
"5e 7x7�M. OD
� •• 'DMS OR M. Latilutle/IongiWtla spume: PS Dropogrsphlc map
th" ton ofwell nbe Shown on a USGS top' map ands#ached to
fs rCoonn i/not ussingg GPSJ
S. FACILITY (Name Of the business Wham the well is I
(�In ..'_L C1i Ocalatl.)
N. DRILLING LOG
i Top Bottom
---Q-l. •. rL
Lit. c2r/'� uses ZIPC
Area rode Phone ",be,
g. WELL DETAILS:
a. TOTAL DEPTH:_��C%�v
h. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 0
C WATER LEVEL Below TOP of CBSIng:
(Use'*'IfAbOvll Topof Casing) —� .
31111hRlt w'tl' I -'3 -
435251
10 CC: & �,
t tl. TOP OF CAGING 18'—�_ 'Top of casing ht"m, FT- Above Land Surface-
avarlancelna 8 or below land aurtace may require
ccnmance WIN IEA NCAC 2C .0119.
i a. YIELD (gpm): Xi
METHOD OF TEST --
Amount
DISINFECTION- Type __
: a. WATER Amount
ZONES (daplh):
TOp�'�. sonom '
Tap Bottom 1. Tap Bottom_
Tap Bottom Top soft.,__
CASING: Depth
L\Ih DIONN
Thickness!
Top r
== Bottom
Weight
Material
Tirp_� Bottom Ft._
�—
--�—
:TUp--__.Beflam�_Ft_
--
—'�—
B. GROUT: Depth
�—
:Top�— Meter)
Boflom�'Q pt
Top Bonom�_ Ft.
_Method
T°P�_ Bottom___ Ft.—
-->—_�
S. SCREEN: Depth DlamOWN
—�
Slot
Top Bottom_ Ft.
Size
Material
TOPp_Ba6om Ft.�in.
in.
TOP_ Bottom._ Ft. In.
__ In.
In.
18. SAND/GRAVEL PACK:
_
--
Depth
TOP__Bono. Ft. She
Mat¢Nal
� T°—Roffom Ft
�—
Tod� ouch m__ �_ FL
Formation Descdpgon
12, REMARKS:
: I OOHEREBICEgnFyTHpTTHIS WELLw
RECOfl�'WELLC°NaTROCHON mgmp,, E°INACCOROANCE WITH
�� BEEN P0.OW0 TOTHE vj'AaD THAT A.11 OF THIS
WELL OWNEq.
SIbNATURE 0 CERTI
-D WELL CONTRA OR UAIE T
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
1 Bi7 NbEl 8ervlca Genter Rala gh'NC 27699etion to- -061, Pho Bf Watfill, Quail
9 @ a9P 936b
1Y.-IlnformetionProceaBing, Form GVLlb
Rev. 2/09

435250
CONTRACTOR
... IJ r6ta.P
r" r Slate 21p Cotl
Lr'' J Ala ]. S Area Moe Phone number
J
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# W:L
OT'HERASSOCIATED PERMIT#(,--p ble) ( I f"•[} ti-( o
SITE WELL ID /Aif epplmNe)_
3. WELL USE —�---
(C"rol.1n3 Agric ltumllU R MunicipalIPublic❑
Intlusiriel/Cmnmerclel❑ Agriculluml
IrrigaiionO Other /' Recovery l� Injection❑
DATE DRILLED q_ 11use) l7yow;.)p YO1 (�=-
4. WBLL LOCATION:
Numbers, Communlry, BRPtlM
LLt N ., Percai, Zip CPtle)
CITY:�Lr,r EI(
�TLLOPOGRgPH10/ �— COUNTY 4v
L951D a LAND BETTING: (ebeµ Pppmhrlah bagq P OVeIIeY ❑Flat ❑Ritlge ❑Other
LATITUDE 38
LONGITUDE,A, tea— "�� "OMS OR 3%.Xg ra
—mu,S. lµa/J "DMS OR 7X X> :ADD
Lalilutleflonyllutle source: pS I]ropogmPhlc map
paX "'M ofwell must ba ahswn on a USGS bpo meta antle#achatl to
this Porn ilnat using GPS)
S. FACILITY (Name Of the business Where the wall Is located.)
Ilitrl �I,. !1
state zip c
Area Sotle nenumber
Lc_
6. WELL DETAILS:
e. TOTAL DEPTH
b. DOES WELL REPLACE EXIS�ELL? YE9
e WATEn LEVE ❑ NO❑
(Use L"jf Ab Top DI Casing:
R AbDWr Tap of Caslnyj �--FT.
�` E OF PERSON CONST
1617 MAIIWill
Iervrf aCe to ( RIIIDiIIIII,,INC2769:0D1�18Phono (919�8p?,ay3� Inlogynatle.pIOCIS aing,
l4 O c" (c It
IFICA"1'ION #
Iona
TOP OF 1'.. CASING
'Top Of catalog ir
"a Landnd
co'
e varlence lne ce NiU 15ANCAC2C .011R.
y require
e. YIELD (Stamp: ,%.
P. DISINFECTION:�jpPa METHOD OF TEST—
0• WATER ZONES —� Anneunt
:Top (a If
e � Bottom
: Top Bottom To Bottom _
IOp Bonom Top Bottom _
Top Bottom__
7. C�A�S�hNO: Depth Thicknsaw
---��— Top iceB°Ilam_ Diameter Weight Metal
_Ft.
_ :Top —
soft, FL
Tn7 B°h°mom FLU—
: 8. GROUT: Depth
J
'TOpg BOliom 3,�FI Materiel �Yy��]��,.,�.rM�e�lh�atl I,
BOSain _ Ff. I T�`_j = -Y—.
TepBoltom�_
Ff.
t.
9, SCREEN: Depth
-_---��— : Top�_Bol(om� Olamatar SI°t Blae Meterlal
TPp�Bottom_ Ft—h. Ft. In.
_
T°P—� Bottom �--__'In. in.
Ft_in.
tD. BANDIGRAV In.
EL PACK:
Oepm
'TOp�_.BOSom_�FI_ Sim
T°p'soSom�—
TOP— FL
Bottom_� Ft_—_
11 DRILLINGLOG --��—
Top Bottom
Formation Description
17. REMARKS: ---
ed
HEREBY CEHTIFY
HOINCA020, THATTHIB WELL WASC°NBiRIrCTEn IN2
:RECORD WELLCONBTRDCfIONUMMRM.ANOT CwROgME WITH
^ nH45 aEENPROVIpEp TO NATACO
bU/�-// $Ifs LLowriE3 m'ov rms
S
AN RE OF CERTIFIED WELL CONTRACTMp -
DATE
PRINTED NA-
RUC—TING
FOOT OW-ib
Rev. 2109

a � D, wa n of W Hcs.111c
as
I1Vo1vREs1
�•�, � f Nonh Car¢frA�'popasau
..-._. ..,.. WLrLL COIV'CIrACTOH
91e1e Zlp Catic
Areacatle Fhona number
2• WELL INFORMATION:
WELL CONSTRUCTION PERMITe
OTHER ATED PERMITp(nappil®hie)--
31TEWELL LLJj3#IIJ#(IrapgiwNel
3. WELL USE (Check One Bux) Manitwi
Inrluetrial/Corapercielp r eO Mu"icipalipublic❑
lrrigallonp Other/ Igncultur,10 Recovery, Injection❑
YI (list use) _Cr-0'te6 rnO 1 DATE DRILLED— 4—_) y - I
A. WELL LOCATION:
it
(Slrent et�lJg NumbeM�' ommury, S1bd1Vslon,Lot NoL� Zt�_.
F�
CITY: ZIP Code)
TO•PO APHIIC /�L -EUND TTING:. (cheUOe Nry
, Stop. []Valley ❑Flat pPrapnete box)`
�RINge []Other
LATITUDE SD _•�: �_ A , DIMS OR 3X.XX--___pIXX pD
5d•
LGNGITUOF+ / I
LatlWnelangiluue sou- - L-2 DMS OR. 7lLXMM2Q% pD
this to n'Ynot must be shr1rr oS a USG, b,a me, entlest oheat to
this /orm i/no! using GPS)
S. FACILITY (Name of the business where the 'Nall Is located.)
(�'I, _ I : _ 1,
Name
/,.I awte ZIP Code
Are. nade _Ph' one number G. WELL DETAILS:
a, TOTAL DEP'PH.
b. DOES WELL REPLACE EXISTING WELL? YES
c. WATER LEVELBeIow Topof Casing;
(Use"+". ifgbove Top of Casing) AFT.
:iluUnilt w'tfi3
_q7"
435249
16'81c('g
tl. TOP OF CASING IS rV
'Top of teeing tenninafetl eVor below lentl suK If Surface -
a" Planes, In eccomanos Wltll ISA cemaY require
:e. YIELD NCAC 2C,011B.
(green).
METHOD OF TEST_-
: L DISINFECTION: Type
Amount
g• WATER ZONES(depth): �—
t Top Bottom
T
Top Bottom Top Bottom
'TaP Bottom ToP----Botom
Top Bono,_
:7, CA INO; Depth Thickness/ —
Top Diameter Weight material
Eaton Ft._
ToP--,_
Bottom Ft.
_ —
T°P—
BWkm--__—Ft.
B. GROUT:
:TOP Q
Depth �—
Metenel
Boltam ����,,,,
...t.L
Methotl
L
F9
' TOPS
Bottom_
F1 - r
Top —,-__
Bottom
Ft ---- —�_
S. SCREEN:
Depth
p --
lamatar
To[,
Bottom_
Slot Slie Material
Top_
BoKom�
Ft.. —in. In..__
Ft.
TDP__�BONom�
—in _— In.
Ft.
In. In.
'a' SANDIGRAVEL PACK:
TollBogom�—FL
.Depth
Size Material
Top
Bottom
To P
m_FI—
—
am —Bolton
11. DRILLING LOG
Top Bottom
xenon ussctlppon
p 12. REMARKS:
ITA HEREBY CERnFY TNgrrme _ • 15g NGC]C, WELL CONST111 vc 1L"Coosr"CTEOINACCORMNC.E WITH
RECORD HAS BEEN PRONOEO TO STA'pARM. ANDT
� /TH OyW1ER. H4TA umP OFTHIS
LrvATURp— `EWELLCONTRq OR'�
OAT
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
1 1 �. D days of completion to. Dwision of Water Quell
1617 Mall DrY be''6eR(erj RaIeIDH� NC 2789g-1IVI IGnO Phone: (9t8) Quality
$--Infeifnetlon Processing, Ferro/09
Rev. 2/U9

Do Ion
L\ESIDENTIAL WELL CONSTRUCTION RECORD
C�o ji raIt@0@lT ant of Enbimnpavmt and Natural Resources - Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 4206
1.WELL CONTRAI;TOYY1'rer Uu lle'1111Onel Operaticos
MICHAEL SLATE
Well Contractor (individual Name)
(DEWEY WRIGHT WELL d PUMP CO., INC.
Well Contractor Company Name
STREETADDRESS P. O. BOX 308
BOONE NC 28607
City or Town State Zip Code
028 Z64-2651
Area code - Phone number
2.WELL INFORMATION:
SITE WELL ID #Iil applicable)
STATE WELL PERMIT #di applicable)
DWO or OTHER PERMIT #di apclmable1W10100418
WELL USE (Check Applicable Box): Residential Water Supp*L]
DATE DRILLED 4,fil 6
TIME COMPLETED03.00 AM ❑ PIO ❑
3. WELL LOCATION
CIT'B!A ru COUNTY AVERY
WELL #1 OFF SUGAR. POINT OFF GROUSE MORE O
(Street Name. Numbers, Community, Subdivision, Lot No., Rental, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑ Slope O Valley ❑ Flat O Ridge O Other
(check appropriate
bozI
May be de®eee,
LATITUDE 3 36'e07.218 mma onds or
LONGITUDE 81-52,736 inad` Lrormat
Latitude/longitedesoozeXI GPS ❑Topographicmap
(location of well must be shown on a USGS tope map and
attached to this tone if not using GPS)
4.WELL OWNER
OWNER'S NAkIffiRISTINE STEWART
STREET ADDREI WOODRIDGE COURT, %HIGHCOUNT
CONCORD NC 29027
City or Town State Zip Code
( 3�3 M 17-76-9800
Areacode - Phone number
5.WELL DETAILS:
a. TOTAL DEPTH: 415
It. DOES WELL REPLACE EXISTING WELL? YES ❑ . NO ❑
a. WATER LEVEL Below Top of Casing: FT.
(Use'4" If Above Top of Casing)'
d. TOP OF CASING IS I FT. Above Lantl Surtace'
Top of casing terminated at/or below land surtace may require
a variance In accordance with 15A NCAC 20 .0118
e. YIELD(guall 50 METHOD OFTESTA:IT- '
435461
I. DISINFECTION: TypeHTH Amount
g. WATER ZONES (depth):
From 30 Tb00 From_ TO-
Fricanni To, From_ To
From To FromTo
6.CASING: Thickness/
Depth
Diameter Weight Material
From
To
Ft.
From o
To 0
Ft.
From
Tbi
Ft.
7.GROUT,
Depth
Material Method
From 0
Tell
FGTRPT/BNT PUMIIBU
From
To
FHB ONTT
Froarr
Ft.
&SCREEN:
Depth
Diameter Slot Size Material
FromToFt._In.
— in.
From_To
Fl in. in.
Roar
To
Ft._ in. in.
9.SAND/GRAVEL PACK
Depth Size Material
From- —To Ft._ —
From_ Tc Ft.
10. DRILLING LOG
From To Formation Description
D 415 GRANITE
.h„A -- +
n
11. REMARKS:
50 GPM 80 - 100 0 GPM -
0GPM -. OGPM -
I DO HEREBY CERTIFYTHATTHIS WELL WAS CONSTRUCTED IN ACCOPDuci WITH
15ANCAC Sri WELL CONSTRUCTION STANDYDS, AND THAT A COW OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF CERTIF DWELL CONTRACTOR DATE
MICHAEL SLATE.
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. 7/05

6...`."Ou
omtalon mvnnerDeeaou:caa
RESIDENTIAL WELL CONSTRUCTION RECORD
N 'aralbQ D2Atfn mOf Envdonment and Ninced Resmmes- Division of Water Quality
WELL CONTRACTOR CERTIFICA'.
t.WELL CONTRAJOR'W for OuailtY Regional Opera ons
MICHAEL SLATE
Well Contractor (individual Name)
DEWEY WRIGHT WELL & PUMP CO., INC. .
Well Contractor Company Name
STREFTADDRESS P. O. SOX 308
EOONE NC 28607
City or Town State Zip Code
072 ?64-2651
Area code - Phone number
2.WELL INFORMATION:
SITE WELL ID #la appicable
STATE WELL PERMIT #Inappllcatla)
DWO or OTHER PERMIT #prapFLcawVnO100418
WELL USE (Check Applicable Box): Residential Water Supp*L]
DATE DRILLED 4/8/2016
TIME COMPLETED03:00 AM ❑ PA
& W EL�LLppELX
LOCATION:
CITY��
.^'-'-'�`COUNTY AVER.Y
WELL 42 OFF SUGAR POINT OFF GROUSE MORE D
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Cade)
TOPOGRAPHIC / LAND SETTING:
❑ Slope O Valley O Flat O Ridge D Other
kh-kepprop I to box) rytey bei degree,
LATITUDE 3 36"0't+.22GN minnt."AYaeD.'
LONGITUDE 81.52.741 in a decimal format
Latitude/longitude source.m GPS ❑ Topographic nwp
(location of Weil must be shown on a USGS tops map and
attached to this form If not using GPS)
4.WELL OWNER
OWNER'S NANO STTNE STEWART
STREET ADOREUHIGH COUNTRY ENERGY SOLUTIONS- PO
GilnA. riJnvn TTry `i.T
(A28) 297-1001
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 290
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NC ❑
c. WATER LEVEL Below Top of Casing: FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS I FT. Above land Surface'
"Top of casing nominated atlor below land surface may require
a variance in accordance with 15A NCAC 20 .0118
e. YIELD(gpm): 20 METHOD OF TESTAir
. 420
435 460
16M
I. DISINFECTION: Type HTH
Amount
g. WATER ZONES (depth):
From 120
T&I-1
From
Ta
From
To
- From_
To
From -
To
From
To
B.CASING
Thickness/
Depth
Diameter
Weight Material
From 0
To
Ft.
From 0
To 0
Ft
From
Toi
Ft.
7.GROUP.
Depth
Material
Method
From 0
To200
ARPT/ONT
PUL.aW
From
To_
Eli EMONTT
FromTo
Ft.
8.SCREEN:
Depth
Diameter Slot Size Material
From
Te
Ft. io.
in,
Fronn
Tc
Ft. in.
in.
From
To
Ft h.
in.
9.SAND/GRAVEL PACK:
Depth
Size
Material
From_To Ft.
10. DRILLING LOG
From To Formation Description
D 290 GRANITE
MAY R 2016
Information FIT ocessv Vn'n`
II. REMARKS:
20 GPM 120 - 121 0 GPM
O GPM - <0 GPM ..
b GPM - 0 GPM -
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRICTED IN ACCORDANCE WITH
I ROAD 2Q WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED 10 IF OWNER.
e 1�/
SI NATURE OFCERTIFIEDWELL CONTRACTOR DATE
MICHAFI RI AT
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt., Form GW-1a
1617 Mail Service Center -Raleigh, NC 27699-1617 Phone No. [phone] ext 568. Rev. 7/05

Ulvlelan of Wniol 0o.roumez
M th
WELLCONTRACTOR
MICHAEL SLATE: _._...
Well Ccntractor Qndividual Name)
DEvvE'v VVRi GHT VVELL d, PUMP CO., INC.
Well Contractor Company Name
P. O. BOX 308
STREET ADDRESS
BOONE NC
28607
City or Town State
Zip Code
�28 ; 64-2651
Area code - Phone number
2.WELL INFORMATION:
SITE WELL ID #Or applicable)
STATE WELL PERMIT#(papplicable)
DWO or OTHER PERMIT #fd apprcabia)
WELL USE (Check Applicable Box): Residential Water Supil
DATE DRILLED 4/8@016
TIME COMPLETEP3 AM O AEI
& WELL LOCATION:
CITy�ELK COUNTY AVERY
WELL #3 OFF SUGAR POINT OFF GROUSEMORE 0
(Street Name, Numbers, Community, Subdivision, Lot No., Forest, Zip Code)
TOPOGRAPHIC/LAND SETTING.
❑ Slope O Valley O Flat O Ridge O Other
(,back eppmpneW borJ
_07223VI eu Mcbe
indegdsppooda.
ma`
LATITUDE 3 m sn or
LONGITUDE _ 81+62.742W ieedecianifpmar
Lafitudellongitude s,nr,e:lt0 CPS ❑ Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER
City Or Town Stale Zip Code
(ISM 1297-1001
Area code - Phone number
S. WELL DETAILS:
a. TOTAL DEPTH: 330
b. DOES WELL REPLACE EXISTING WELL? YES❑ NVOO
c. WATER LEVEL Below Top of Casing: FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS I FT Above Lend Surface'
Top of casing terminated abler below land surface may require
a varlance in accordance with 15A NCAC 20.0118
e. YIELD (gpm): 12 METHOD OF TESTA Ir
NSTRUCTIOiN RECORD 435459
Resources- Division of Water Quality
4M - 16DOV
I. DISINFECTION: Type NTH Amount
g. WATER ZONES (depth);
From 120 T621 From_ To
From To- From To
From To From To
6.CASING: Thickness/
From
From 0
From
Depth
To
Tc U
To
Diameter Weight
Ft.
Ft.
Ft.
Material
7.GROUT.
Depth
Material
Method
From o
To330
F9RPTi PUMPED
FromTo
0+8'71TONIT
FromTo_
Ft.
&SCREEN:
Depth
Diameter Slot Size
Material
From
Tc
Ft. in. in.
FromTo
Ft.In. In.
FromTo
F1._In. _In.
9,SAND/GRAVEL PACK:
Depth
Size
Material
From_
To
Ft.
From
To
Ft.
From_
To
Fit
10. DRILLING LOG
From To Formation Description
U 3a GRANITE
MAY X 4 2019
Ialu ml iion Process'Ing Una
A
11. REMARKS:
12 GPM 120-.121 0 GPM
0 GPM - 0 GPM -
OGPM - 0GPM ..-
I DO HEREBY CERTIFY THATTHIS WELL WAS CONSTRUCTED IN ACOONOANCE WITH
HA NCAC 20, WELL CONSTRUCTION STANDARDS, ANN THATA COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIG ATUREOFCERTIFIEDWELLCONTRACTOR DATE
MICHAEL SLATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt., Form GW-1a
1617 Mall Service Center -Raleigh, NC 27699-1617 Phone No. [phone] ext568. Rev. 7/05

I,I i ,
o D,oiw) RESIDENTIAL WELL CONSTRUCTION RECORD
MIA droinuaQlmrment of Environment and Natural Resources -Division of Water Quality
WELL CONTRACTOR CERTIFICATION k 4296
1.WELL CONTRACTOR "'"""
MICHAEL SLATE -
Well i�•
Contractor (individual Name)
OEVVEV VVRIGHT VSIELL & PUMP CO., INC.
Well Contractor Company Name
STREETADDRESS AO'BOX ICE
BOONE NC 28607
City or Town State Zip Code
�28 ?,64-2651
Area code - P one -number
2. WELL INFORMATION:
SITE WELL ID en appliablel
STATE WELL PERMIT #(If applicable)
DWO or OTHER PERMIT #(n appii.ci r)"ICIQC41$
WELL USE (Check Applicable Box): Residential Water SUpplIN
DATE DRILLED 4/6/2016
TIME COMPLETED03'00 AMU AU
&WELL LOCATION:
CIT41ANNT COUNTY AVERY
WELLH4 OFF SUGAR POINT OFF GROUSE MORE OF
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑ Slope O Valley O Flat O Ridge O Other
(check appropriate box)
Mnyb dgrce
as -to,
LATITUDE 3 m t:, aergadesor
LONGITUDE row docii mreast
Latituderoldilude sosree:XO GPS O Topographic map
(location of well must be shown on a USGS topic map and
attached to this form If not using GPS)
4.WELL OWNER
OWNER'S NANWIRISME SMW'ART
( ID i7AT-1Wl
Area coda - Phone number
Si DETAILS:
a. TOTAL DEPTH: 330
b. DOES WELL REPLACE EXISTING WELL? YES IX❑
c. WATER LEVEL Below Tap of Casing: FT.
(Use '+" if Above Top of Casing)
d. TOP OF CASING IS I FT Above Land Surface`
'Top of casing terminated atlor below land surface may require
a variance In accordance with 15A NCAC 2C .0118
e. YIELD hipri 3 METHOD OF TEST) r
435458
f. DISINFECTION: Type HTH Amount
9. WATER ZONES (depth):
From 110 TO' Froni To
Firm To Fmni To
From To From To
6.CASING: Thickness/
Depth
Diameter
Weight Material
- From -
To
Ft.
From 0.
To C
Ft.
From
To
Pt.
7.GROUT.
Depth
Material
- Method
From 0
1330
�{RYFBNT
PUlaw
From
To
Ih'iI STONIT
From
To
R.
e.SCREEN:
Depth
Diameter Slot Size Material
From_ToFt.in.
In.
From
To
Ft. In.
_In.
From —To
Ft._Jn.
in.
9.SAND/GRAVEL PACK:
Depth
Size
Material
From_ To Ft.
10. DRILLING LOG
From To Formation Description
0 330 GRANITE
BWQIa^r=
11. REMARKS:
E GPM 120 -121 OGPM
O GPM - 0 GPM -
0 GPM 0 GPM -
iDO HEREBY CEBTIFYTHATTHIS WELLWAS CONSTRUCTED IN ACCORDANCE WITH
EA NCA020. WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN
PROVIDED TOO THEE WELL OWNER.
SIGNATURE OE CERTIFIED WELL CONTRACTOR DATE
MICHAEL SLATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt., Form GW-1a
1617 Mail Service Center -Raleigh, NO 27699-1617 Phone No.,[phone] ext 588. Rev. 7/05

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