385894_Well Construction - GW1_20100101

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2436A
1 WELL CONTRACTOR
DERRICK HEATH SAWYERS
Well Contractor (Individual) Name
CLYDE SAWYERS & SON WELL & PUMP IN6
Well Contractor Company Name
14885 HWY 209
Street Address
HOT SPRINGS NC 28715
City or Town State Zip Code
( 828 ) 665-2022
Area code Phone number
2 WELL INFORMATION•
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply [�
DATE DRILLED 5-27-10
TIME COMPLETED 4:00 AM ❑ PM l5(
4 WELL LOCATION.
CITY BARNARDSVILLE COUNTY BUNCOMBE
PAINT FORK ROAD
(Street Name, Numbers, Community, Subdivision, Lot No Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING
DSlope ❑ Valley ❑Flat ❑ Ridge
LATITUDE 36
LONGITUDE 75
(check appropnate box)
❑Other
" DMS OR 3x XXXXXXXXX DD
" DMS OR 7x XXXXXXXXX DD
Latitude/longitude source J3PS OTopographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5 WELL OWNER
ALVIN FULLER
Owner Name
PAINT FORK ROAD
Street Address
BARNARDSVILLE
City or Town
(--)
Area code Phone number
6 WELL DETAILS
a. TOTAL DEPTH: 280
b DOES WELL REPLACE EXISTING WELL? YES E NO C'
c WATER LEVEL Below Top of Casing 40 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) 50 METHOD OF TEST RIG
NC 28787
State Zip Code
f DISINFECTION Type PILLS Amount 18
0
g WATER ZONES (depth)
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
7 CASING Depth
Top 0 Bottom 80
Top Bottom
Top Bottom
8 GROUT
Top 0
Thickness/
Diameter Weight Material
Ft 6 25" #21 PLASTIC
Ft
Ft
Depth Material
Bottom 20 Ft CEMENT
Top Bottom Ft
Top Bottom Ft
9 SCREEN Depth Diameter
Top Bottom Ft in
Top Bottom Ft in
Top Bottom Ft in
10 SAND/GRAVEL PACK.
Depth
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
0 /80
Size
Method
POURED
Slot Size Material
in
In
in
Material
Formation Descnption
OVER BURDEN
80 /280 GRANITE
12 REMARKS
JUL 2 7 2010
Inform2:ie,1 rrocessing Uri
Q/80G %t
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER
5-27-10
SIGNATURE OF CERTIFIED WELL CONIIRACTOR DATE
DERRICK HEATH SAWYERS
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,
TMS
JAN 0 7 2013
Form GW-1a
Rev 2/09