GW1--06553_Well Construction - GW1_20231006

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', •� RESIDENTIAL WELL CONSTRUCTION R,CORD-
V 1 ' North Carolina Department of Environment and Natural Resources-Division of Water Quality
�. WELL CONTRACTOR CERTIFICATION# 3489 230090
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1.WELL CONTRACTOR: f. DISINFECTION:TypeI'HTH Amount 73
RICKY HUFFMAN g. WATER ZONES(depth):
Well Contractor(Individual)Name
From 120 To 130' From 320 To 340
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: I' Thickness/
Depth Diameter Weight Material
BOONE NC 28607 From 1) To 63 Ft. 6 1/4 188 GAI V
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 i Ft. BENTONIT GRAVITY
-- - -- ---SITE WELL ID#(ifapplicable)-- '_ -- --- -� - --_ - rom�. � To— JI Ft. 1-8BAGS _ _ - -- --
WELL CONSTRUCTION PERMIT#393746 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 9/28/2023 From To 'Ft. in. in.
TIME COMPLETED 03:00 AM 0 PM IIX From To Ft. in. in.
4.WELL LOCATION: 10.SAND/GRAVEL PACK:
CITY: BOONE COUNTY WATAUGA - Depth • Size Material
From To Ft.
LOT#4 POPLAR FOREST SUBDIVISION.OFF HOW From • To ' Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) From To Ft.
TOPOGRAPHIC/LAND SETTING: ,
0 Slope 0 Valley X Flat 0 Ridge 0 OtherI.
11. DRILLING LOG
• (check appropriate box) May be in degrees, From To Formation Description
LATITUDE — 36.25005N minutes,seconds or 0 51 DIRT GRAVEL
LONGITUDE 81.68143W in a decimal format 51 120 GRANITF
— — 120 130 QUARTZ
Latitude/longitude source: X GPS 0 Topographic map 130 280 GRANITE
(location of well must be shown on a USGS topo map and 280 320 SHALE
attached to this form if not using GPS) 320 340 GREEN GRANITE
340 405 GRANITE r,+.ice^ --. .7---
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5.WELL OWNER �, ,, ., "7- ,.,•;-,
OWNER'S NAME MARK&PATRISHA RUSSELL 6 -,
STREET ADDRESS 404 HASBROUCK DR OCT Q G 202
APEX NC 27523 —IF'�rr1"•? ^� 7.,•_s
City or Town State Zip Code r,, y .1`.N�w"'' I rr
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. ( 919 )_ 345-4851
Area code- Phone number IZ. REMARKS: ,,
2 GPM 120 130 I'
• 6.WELL DETAILS: 2 GPM 320-340 1 .,
a. TOTAL DEPTH: 405
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: 40 FT. RECORD HAS BEEN PROVI EDT THE WELL OWNER.
(Use"+"if Above Top of Casing) i '
d. TOP OF CASING IS 1 •.'':FT.Above Land Surface* / �`O`�•
*Top of casing terminated at/or below land surface may require SIGNATUR OF. ERTI WELL CONTRACTOR DATE
a variance in accordance with 15A NCAC 2C.0118...--c 1
RICKY HUFFMAN
e. YIELD(gpm): 4 METHOD OF TEST AIR 5 PRINTED NAME OF PERSON CONSTRUCTING THE WELL
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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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