GW1--06827_Well Construction - GW1_20231023

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g „r, �•- RESIDENTIAL WELL CONSTRUCTION RECORD
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5 North Carolina Department of Environment and Natural Resources-Division Water Quality
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"".,�'0,0' WELL CONTRACTOR CERTIFICATION# 3489 230028
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount 22
RICKY HUFFMAN
g. WATER ZONES(depth):
Well Contractor(Individual)Name
From 90 To 98 From 110 To 111
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 40 Ft. 6 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
From 0 To 20 Ft. BENTONIT GRAVITY
SITE WELL ID#(if applicable) From To Ft.l$ BAGS
WELL CONSTRUCTION PERMIT# 154253 From To ` 1Ft.
OTHER ASSOCIATED PERMIT#(if applicable)
9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply IX From To Ft. in. in.
DATE DRILLED 10/9/2023 From To Ft. in. in.
TIME COMPLETED 03:00 AM II PM IX From To Ft. in. in.
4.WELL LOCATION: 10.SAND/GRAVEL PACK:
CITY: LANSING COUNTY ASHE Depth Size Material
From To Ft.
OFF E LITTLE HORSE CREEK OFF 194 OFF 221 0 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 Other •
(check appropriate box) 11. DRILLING LOG
May be in degrees, From To Formation Description
LATITUDE — — 36.51691N minutes,seconds or 0 30 DIRT
LONGITUDE 81.54602W in a decimal format 30 90 GRANITE
— — 90 98 GREEN GRANITE
Latitude/longitude source: X GPS o Topographic map 98 110 GRANITE
(location of well must be shown on a USGS topo map and 110 111 VOID
attached to this form if not using GPS) 111 122 GRANITE
5.WELL OWNER I
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OWNER'S NAME ELMER STANSBERRY ,�.., - ,r---N,:;.,_r ,.,,r;r-• ;) ;i
r.STREET ADDRESS 1502 LONG BRANCH RDA'"�"r tt �y-
Ann
LANSING NC 28643 — OCT q, J4 ZI
City or Town State Zip Code r ;,;;,
336 620-3747 -a,--.'.`a G: ;)
Area code- Phone number
12. REMARKS: D vw3
2 GPM 90-98
6.WELL DETAILS: 38 GPM 110 111
a. TOTAL DEPTH: 122 i .
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 PROV D TO THE WELL OWNER.
(Use"+"if Above Top of Casing) �1
d. TOP OF CASING IS 1 FT.Above Land Surface` /q 6 lG'a(��i3
*Top of casing terminated at/or below land surface may require SIGNATU E OF C TIFIED WELL CONTRACTOR DATE
a variance in accordance with 15A NCAC 2C.0118. RICKY HUFFMAN
e. YIELD(gpm): 40 METHOD OF TEST AIR PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Informatiok Mgt., Form GW-la
1617 Mail Service Center-Raleigh, NC 27699-1617 Phone No.[phone] ext 568. Rev.3/07

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