GW1--02993_Well Construction - GW1_20240513

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' %.' RESIDENTIAL WELL CONSTRUCTION RECORD
}� North Carolina Department of Environment and Natural Resources-Divisionlof Water Quality
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WELL CONTRACTOR CERTIFICATION# 3489 240075 -
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1.WELL CONTRACTOR: f. DISINFECTION:Type!HTH r Amount 91
RICKY HUFFMAN
g. WATER ZONES(depth):
Well Contractor(Individual)Name
. From 190 To 210;; . From 281 To 340 -
DEWEY WRIGHT WELL&PUMP CO., INC From 480 To 510' From To
Well Contractor Company Name From To 1 ' From To • '
STREET ADDRESS PO BOX 308 7. CASING: Thickness/
Depth Diameter Weight Material
BOONE NC 28607 From p To 35 I Ft. 5 1/8 350 PVC
City or Town State Zip Code From To I 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---fFt--2-3 BAGS -_
WELL CONSTRUCTION PERMIT#039809 From To l'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 5/1/2024 From To Ft. in. in.
TIME COMPLETED 03:00 AM PM X From To Ft. in. in.
4.WELL LOCATION: • 10.SAND/GRAVEL PACK: ' t
BANNER ELK COUNTY AVERY Depth Size 1::::,a-••1`latetiai : •,�3
CITY: .6., r 1.—I. r::.
• From -To ,'Ft. _
LOT#N-114 OFF EAGLE PARK DR OFF EAGLES NI From, To ,Ft. MAY 1 '2024
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) From To Ft.
TOPOGRAPHIC/LAND SETTING: Ira r.<^..i•'..,e: ir37-•!.w'.,zii%!tipi,
Slope Valley X Flat Ridge Other 11. DRILLING LOG C6' t -BOG
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(check appropriate box)
May be in degrees, From To t Formation Description
LATITUDE , _ 36.215343 minutes,seconds or D 20 BROWN SHELL
LONGITUDE 81.912441 in a decimal format 20 190 . GRANITF
190 210 GRFFN GRANITF
Latitude/longitude source: X GPS Topographic map 210 280 GRANITE
• (location of well must be shown on a USGS topo map and 280 281 BROWN;SHELL
• attached to this form if not using GPS) 281 340 GREYIRED GRANITE MIX
340 341 BROWNISHELL
5.WELL OWNER 341 480 GRANITE
OWNER'S NAME JOHN LEIGHTON 480 510 GREY RED GRANITE MIX
STREET ADDRESS PO BOX 1273 , 510 605 GRANITE
STUART FL 34995
City or Town State Zip Code
(772 )_ 263-0500
Area code- Phone number • 12. REMARKS:
1 GPM 190-210
6.WELL DETAILS: • 4 GPM 281-340 I
a. TOTAL DEPTH: 600 1 GPM 480-510
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b. DOES WELL REPLACE EXISTING WELL? YES NOX I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH •
15A NCAC 2C,WELL CONSTRUCTION SjTANDARDS,AND THAT A COPY OF THIS
C. WATER LEVEL Below Top of Casing: 160 _ FT. RECORD HAS BEEN PROVIDED TO E WELL OWNER.
(Use"+"if Above Top of Casing) 1; i
d. TOP OF CASING IS 1 FT.-Above Land Surface* > -ac.2�
*Top of casing terminated at/or below lahci'surface may require SIGNATURE ERTIFI 'WELL CONTRACTOR DATE
a variance in accordance with 15A NCAC;2C0118. RICKY HUFFMAN
e. YIELD(gpm): 6 METHOD OFTEST 'AIR-1.'... _.._ 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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