385892_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
CLYDE SAWYERS & SON WELL & PUMP IN6
Well Contractor Company Name
14885 HWY 209
Street Address
HOT SPRINGS NC 28743
City or Town State Zip Code
( 828) 665-2022
Area code Phone number
2 WELL INFORMATION.
WELL CONSTRUCTION PERMIT# 2010-00173
OTHER ASSOCIATED PERMIT#(4 applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check Applicable Box) Residential Water Supply i
DATE DRILLED 6-02-10
TIME COMPLETED 4.00 AM ❑ PM C(
4 WELL LOCATION
crrY WEAVERVILLE CouNTY BUNCOMBE
NEW STOCK ROAD 28787
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING
❑Slope E'Valley ❑Flat ❑ Ridge
LATITUDE 35
LONGITUDE 82
73 . 546 000
(check appropnate box)
❑Other
0 "DMS OR 3x XXXXXXXXX DD
" 59 • 111 000
0 " DMS OR 7x XXXXXXXXX DD
Latitude/longitude source 13PS ❑Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5 WELL OWNER
MICHELLE MOSS
Owner Name
NEW STOCK ROAD
Street Address
WEAVERVILLE
City or Town
( )
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 205
b DOES WELL REPLACE EXISTING WELL YES ❑ NO LEI
WATER LEVEL Below Top of Casing 80 FT
(Use "+" if Above Top of Casing)
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
YIELD (gpm) 8 METHOD OF TEST RIG
DISINFECTION Type PILLS Amount 15
c
d
e
f
NC 28787
State Zip Code
g" WATER ZONES (depth)
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
7 CASING Depth Diameter
Top 0 Bottom 66 Ft 6 25"
Top Bottom Ft
Top Bottom Ft
9 f' 1' r?
tY _ z: 0
4.4
Thickness/
Weight Material
#21 PLASTIC
8 GROUT Depth Material Method
Top 0 Bottom 20 Ft CEMENT POURED
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 Size
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
0 /66
/
66 /205
/
/
/
Slot Size Material
in
in
in
Material
Formation Descnption
OVER BURDEN
GRANITE
/ • ems( '�, .�
/
/ JUi 2 7 207u
12 REMARKS
information P
DWQ/ procGsfn9 Unit
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
SIGNATUREI
OF C ED WELL ONTRA OR 6 DATEE
DERRICK HEATH SAWYERS
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
lk'.
Submit within 30 days of completion to. Division of Water Quality - Information Processt g ��
1617 Mail Service Center, Raleigh, NC 27699-161, Phone [phone]
JAN 1 1 2013
Form GW-la
Rev 2/09