GW1--04133_Well Construction - GW1_20240717

.a STATE,;
g { .t', RESIDENTIAL WELL CONSTRUCTION RECORD
J I if ,6 North Carolina Department of En ironment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 3489 240075-1
1.WELL CONTRACTOR: f. DISINFECTION:Type HTH Amount
RICKY HUFFMAN g. WATER ZONES(depth):
Well Contractor(Individual)Name
From 0 To 605 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 To Ft.
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 To Ft.
SITE WELL ID#(if applicable) From To Ft.
WELL CONSTRUCTION PERMIT#039809 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 7/3/2024 From To Ft. in. in.
TIME COMPLETED 03:00 AM PM X From To Ft. in. in.
4.WELL LOCATION: 10.SAND/GRAVEL PACK:
CITY: BANNER ELK COUNTY AVERY Depth Size Material
From To Ft.
LOT#N-114 OFF EAGLE PARK DR OFF EAGLES N• From To Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) From To Ft.
TOPOGRAPHIC/LAND SETTING:
Slope Valley Flat Ridge Other 11. DRILLING LOG
(check appropriate box)
May be in degrees, From To Formation Description
LATITUDE — 36.215343 minutes,seconds or 0 605 EXISTING
LONGITUDE 81.912441 in a decimal format 605 705 GRANITF
Latitude/longitude source: X GPS Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
5.WELL OWNER b • 4
OWNER'S NAME JOHN LEIGHTON �`�`'�'�• ,`
� '—
STREET ADDRESS PO BOX 1273 JUL 1 7 2024
STUART FL 34995
City or Town State Zip Code trier q-,c r„ 79-nran��•,1 Ufa
( 772 )- 263-0500
Area code- Phone number 12. REMARKS:
6 GPM 0-605
6.WELL DETAILS:
a. TOTAL DEPTH: 705
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 STANDARDS,AND THAT A COPY OF THIS
c. WATER LEVEL Below Top of Casing: 310 FT. RECORD HAS BEEN PROVIDED T• HE WELL OWNER
(Use"+"if Above Top of Casing)
2A:ji •
��d. TOP OF CASING IS 1 FT.Above Land Surface*
*Top of casing terminated at/or below land surface may require SIGNATUUO CERT)'' D WELL CONTRACTOR DATE
a variance in accordance with 15A NCAC 2C.0118. RICKY HUFFMAN
e. YIELD(gpm): 6 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-la
1617 Mail Service Center—Raleigh, NC 27699-1617 Phone No. [phone] ext 568. Rev.3/07

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