GW1--07619_Well Construction - GW1_20231204

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Q�'`. RESIDENTIAL WELL CONSTRUCTION RECORD -
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b �y ` North Carolina Department of Environment and Natural Resources-Division of Water Quality
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• K'. } WELL CONTRACTOR CERTIFICATION# 3489 230134
1.WELL CONTRACTOR: f. DISINFECTION:Type,.HTH Amount 85
RICKY HUFFMAN g. WATER ZONES(depth): _
Well Contractor(Individual)Name From 280 To 310 From 360 To 361
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 1 Diameter Weight Material
BOONE NC 28607 From 0 To 40 Ft. 6 1/8 350 PVC
City or Town State Zip Code From To F.
(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:-25 BAGS
WELL CONSTRUCTION PERMIT#389734 From ~` To ,I Ft.
OTHER ASSOCIATED PERMIT#(if applicable)
9. SCREEN: Depth , Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply ID( From To '. Ft. in. in.
DATE DRILLED 11/6/2023 From To Ft. in. in.
TIME COMPLETED'03:00 AM 0 •PM DX From To " Ft. in. in.
4.WELL LOCATION: 10.SAND/GRAVEL PACK:
CITY: CRUMPLER COUNTY ASHE Depth Size Material
From To Ft.
OFF SMITHEY RD OFF OLD 16 OFF S.OVERPASS From To Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) From To Ft.
TOPOGRAPHIC/LAND SETTING:
0 Slope 0 Valley 0 Flat II Ridge 0 Other ,
(check appropriate box) 11. DRILLING LOG
May be in degrees,, From To Formation Description
LATITUDE — 36.53250N minutes,seconds or 0 30 DIRT
LONGITUDE 81.38296W in a decimal format 30 170 GRANITE
— — 170 200 SHALE.
Latitude/longitude source: X GPS u Topographic map 200 280 GRANITE
(location of well must be shown on a USGS topo map and 280 310 QUARTZ
attached to this form if not using GPS) 310 360 GRANITE
360 361 VOID '
5.WELL OWNER 361. 405 GRANITE
OWNER'S NAME JUSTIN CHURCH
STREET ADDRESS 285 CEDAR RIDGE DR -
MILLERS CREEK NC 28651 •- '-
City or Town State Zip Code r_-.. - -:,- ,
(336 )- 657-4999 t :,.c-_ O...:,is -,L.
Area code- Phone number 12. REMARKS:
6 GPM 280-310 �G.�', 2�23
6.WELL DETAILS:
24 GPM 360-361
a. TOTAL DEPTH: 405. ,;,•,-...'. .. .,,,..-. __ ,_,.:__ ;,.,u
r+
b. DOES WELL REPLACE EXISTING WELL? YES 0 NOX a
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTEUCTE IN D IN ACCORDANCE WITH
15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
c. WATER LEVEL Below Top of Casing: + FT. RECORD HAS BEEN PROVIDED TOTHE WELL OWNER.
(Use"+".if Above Top of Casing)
t
d. TOP OF CASING IS 1 FT.Above Land Surface* r� t r- 2Va`3
*Top of casing terminated at/or below land surface may require SIGNATU OF CER FIED WELL CONTRACTOR DATE
a variance in accordance with 15A NCAC 2C.0118. RICKY HUFFMAN j
e. YIELD(gpm): 30 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-1 a
1617 Mail Service Center-Raleigh,NC 27699-1617 Phone No.[phone] ext 568.I Rev.3/07

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