388713_Well Construction - GW1_20100101

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RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 4022-A
1 WELL CONTRACTOR
DERRICK SCOTT LEDFORD
fJ61, ,. b r.
g WATER ZONES (depth)
Top Bottom Top Bottom
Well Contractor (Individual) Name Top Bottom Top Bottom
CLYDE SAWYERS AND SON WELL DRILL Top Bottom Top Bottom
Well Contractor Company Name
Thickness/
14885 HWY 209 7 CASING Depth Diameter Weight Material
Street Address Top 1 FT Bottom 74 Ft 6 25" #21 PVC
HOT SPRINGS NC 28743 Top Bottom Ft
City or Town State Zip Code
( 828 ) 665-2022 Top Bottom Ft
Area code Phone number 8 GROUT Depth Material Method
2 WELL INFORMATION Top 0 Bottom 20 Ft CEMENT POURED
WELL CONSTRUCTION PERMIT# 2010-00456 Top Bottom Ft
OTHER ASSOCIATED PERMIT#(if applicable) Top Bottom Ft
SITE WELL ID #(if applicable) 9 SCREEN Depth Diameter Slot Size Material
3 WELL USE (Check Applicable Box) Residential Water Supply IV Top Bottom Ft in to
DATE DRILLED 10-05-2010 Top Bottom Ft in in
�/ Top Bottom Ft in to
TIME COMPLETED 10'30 AM Ly PM ❑
4 WELL LOCATION 10 SAND/GRAVEL PACK
Depth Size Material
cm( fairview COUNTY buncombe
Top Bottom Ft
46 Gibson Roberts Drive Fairview. NC Top Bottom Ft
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code) Top Bottom Ft
TOPOGRAPHIC / LAND SETTING (check appropnate box)
DSlope IIValley ❑Flat ❑ Ridge ❑ Other
LATITUDE 35 532 647 0000 DMS OR 3x XXXXXXXXX DD
LONGITUDE 82
412 462 0000 „ DMS OR 7x xxxxxxxxx DD
Latitude/longitude source E 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
CAROLYN FORTNER
Owner Name
46 GIBSON ROBERTS DRIVE
Street Address
FAIRVIEW
City or Town
(828 ) 628-1531
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 205 FT
NC 28730
State Zip Code
b DOES WELL REPLACE EXISTING WELL? YES 0 NO g
c. WATER LEVEL Below Top of Casing 40 FT FT
(Use "+" if Above Top of Casing)
d TOP OF CASING IS 1 FT 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
11 DRILLING LOG
Top Bottom
0 /74
Formation Description
OVER BURDEN
74 /205 FT GRANITE
/ [ IT
/ nlnv 11 9 701U
PioG•:SStn9 Unit
/ DWQ/BOG
/
12 REMARKS
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STAND S, AND THAT A COPY OF THIS RECORD HAS BEEN
RROVA TO THE WELL ! WNER
!/
ATURE OF CERTIFIED W�AC'.R DATE
DERRICK SCOTT LEDFORD
10-12-2010
PRINTED NAME OF PERSON CO
114,
THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Process 4 2013
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-la
Rev 2/09