GW1--07622_Well Construction - GW1_20231204

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T } RESIDENTIAL WELL CONSTRUCTION RECORD
�� North Carolina Department of Environment and Natural Resources-Division of Water Quality
`''. ,•- ',: WELL CONTRACTOR CERTIFICATION# 3489 220201
1.WELL CONTRACTOR: f. DISINFECTION:Type iH(.TH "- Amount 76
RICKY HUFFMAN g. WATER ZONES(depth): '
Well Contractor(Individual)Name From 340 To 3501 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 88 Ft. 6 1/4 .188 GALV
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 applicable) From 0 To 20 ! Ft. BENTONIT GRAVITY
_ _. From To Ft.-60 BAGS _ - — -• --
'WELL CONSTRUCTION PERMIT#366500 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 11/9/2023 From To Ft. in. in:
TIME COMPLETED 03:00 AM O PM OX From To Ft. in. in.
4.WELL LOCATION: 10.SAND/GRAVEL PACK:
CITY: WEST JEFFERSON COUNTY ASHE Depth Size Material
From To Ft. •
OFF MEGAN OFF BUCK MTN OFF BUCK MTN CIRI 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 — — 36.39929N minutes,seconds or 0 80 DIRT;MUD
LONGITUDE 81.51309W in a decimal format 80 190 GRANITE
— — 190 225 SHALE
Latitude/longitude source: X GPS o Topographic map 225 340 GRANITE
(location of well must be shown on a USGS topo map and 340 350 QUARTZ
attached to this form if not using GPS) 350 405 GRANITE
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5.WELL OWNER I
OWNER'S NAME CARLOS PENA
STREET ADDRESS 904 LACONIA CT
VIRGINIA BEACH VA 23464 - .
City or Town State Zip Code
( 757 )_ 355-2252 . DEC ' 2023
Area code- Phone number 12. REMARKS:
5 GPM 340-350 1
6.WELL DETAILS: )rs+v.';..,1i i t¢.xf.:,. :0 f}t;t'
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: 20 FT. RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
(Use"+"if Above Top of Casing) f , "r I
d. TOP OF CASING IS'. 1 FT.Above Land Surface* � /f f✓�-2 ?
*Top of casing terminated at/or below land surface may require SIGNATUR yOF CERTIF D, ELL CONTRACTOR DATE
a variance in accordance with 15A NCAC 2C.0118. RICKY HUFFMAN , '
e. YIELD(gpm): 5 METHOD OF TEST AIR , PRINTED NAME OF PERSON CONSTRUCTING THE WELL,.
Submit the original to the Division of Water Quality within 30 days. Attn:Informatlion'Mgt., Form GW-la
1617 Mail Service Center—Raleigh, NC 27699-1617 Phone No.[phone] ext 568. 1 ' Rev.3/07

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