388716_Well Construction - GW1_20100101

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2436-A
1 WELL CONTRACTOR
DERRICK HEATH SAWYERS
Well Contractor (Individual) Name
g WATER ZONES (depth)
Top Bottom Top
Top Bottom Top
CLYDE SAWYERS AND SON WELL DRILL Top Bottom Top
Well Contractor Company Name
14885 HWY 209 7. CASING Depth Diameter
Street Address
HOT SPRINGS
City or Town
( 828 ) 665-2022
Area code Phone number 8 GROUT Depth Material
2 WELL INFORMATION. Top 0 Bottom 20 Ft CEMENT
WELL CONSTRUCTION PERMIT# Top Bottom Ft
Top 0 Bottom 73 Ft 6 25"
Top Bottom Ft
Top Bottom Ft
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply [Jf
DATE DRILLED 08-12-2010
TIME COMPLETED 3:30 AM ❑ PM Of
4 WELL LOCATION 10 SAND/GRAVEL PACK
CITY FAIRVIEW COUNTY BUNCOMBE TopDBepth
ottom Ft
Top Bottom Ft
Bottom
Bottom
Bottom
Thickness/
Weight Material
#21 PVC
Method
POURED
9 SCREEN Depth Diameter Slot Size Material
Top Bottom Ft in in
Top Bottom Ft in in
Top Bottom Ft in in
30 CHINHILLS LANE
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑ Slope tjValley 0 Flat ❑ Ridge 0 Other ,
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
LATITUDE 35 53,3830000n DMS OR 3x XXXXXXXXX DD /
LONGITUDE 82
43,531 0000 " DMS OR 7x XXXXXXXXX DD
Latitude/longitude source t 3PS ['Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5 WELL OWNER
STEVE PACK
Owner Name
30 CHINHILLS LANE
Street Address
FAIRVIEW
NC
City or Town
�)
Area code Phone number
State Zip Code
6 WELL DETAILS
a. TOTAL DEPTH. 285
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO iyr
c WATER LEVEL Below Top of Casing 40 FT FT
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS 1 FT Above Land Surface*
*Top of casing terminated at/or below land surface may require
a vanance in accordance with 15A NCAC 2C 0118
e YIELD (gpm) 6 METHOD OF TEST RIG
f DISINFECTION Type PILLS Amount 12
0 /73
73 /285
/
12 REMARKS
Size Material
Formation Description
OVER BURDEN
GRANITE
p i A4.IP—rr•-%
' tr IJ
N01/ AD
Lulu
Information D-
DWQ/BOG
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL C. STRUCTION
STAND DS, AND THAT A COPY OF THIS CORD HAS BEEN
PRO P: D TO THE ELL O NER
GNATURE OF CERTIFIED WELL
DERRICK HEATH SAWYERS
TRAM OR
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality -
1617 Mail Service Center, Raleigh, NC 27699-161, Phone . [phone]
Information Processing,
Form GW-la
•4 Rev 2/09