387452_Well Construction - GW1_20100101

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural ResourLes- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3500
1 WELL CONTRACTOR
Chad Surrett
Well Contractor (Individual) Name
AWD Services Inc
Well Contractor Company Name
258 North Turkey Crk Rd
Street Address
Leicester
City or Town
L828 ) 683-9223
Area code Phone number
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT# 2009-00460
g WATER ZONES (depth)
Top 0 Bottom 120 Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7 CASING Depth Diameter Weight Material
TopO Bottom 58 Ft 61/4" SDR2 PVC
NC 28748 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 Uv
DATE DRILLED 5/10/2010
TIME COMPLETED AM 0 PM 0
4 WELL LOCATION
CITY Woodfin COUNTY Buncombe
12 Inale Rd Asheville NC 28804
(Street Name Numbers Community, Subdivision, Lot No , Parcel Zip Code)
TOPOGRAPHIC / LAND SETTING
I4fSlope ❑ Valley ❑ Flat ❑ Ridge
LATITUDE 35
° 37 ' 54 0000
LONGITUDE 82
° 36
(check appropriate box)
❑OthereleV 2092
"DMS OR 3x xxxxxxxxx DD
Latitude/longitude source VGPS
(location of well must be shown on a
this form if not using GPS)
5 WELL OWNER
Georae Baraer
" DMS OR 7x xxxxxxxxx DD
pfopographic map
USGS topo map andattached to
Owner Name
12 Inale Road
Street Address
Asheville NC 28804
City or Town State Zip Code
( )
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 285'
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO IRr
c WATER LEVEL Below Top of Casing 80 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 variance in accordance with 15A NCAC 2C 0118
e
YIELD (gpm) 1 METHOD OF TEST aal contaliEi
DISINFECTION Type tablet Amount 2
Top Bottom Ft
8 GROUT
Top 0
Top
Top
Depth Material
Bottom 21 Ft Concrete
Bottom
Bottom
9 SCREEN Depth
Top Bottom
Top Bottom
Top Bottom
Ft
Ft
Method
Pour
Diameter Slot Size Material
Ft
Ft
Ft
10 SAND/GRAVEL PACK
Depth
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
14 /
/
/
/
12
REMARKS
in m
m in
in
Size
In
Material
Formation Description
SEP-1 T-MO
I DO HEREBY CERTIFY THAT'T'f WELL WAS4 QNS;T1VCTED IN
ACCORDANCE WITH 15A NCAC 2C,�V'VEhL(GONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER
,A0V-71L--
SIGNATURE OF CERTIFIED WELL CONTRACTOR
Chad Surrett
5/13/2010
DATE
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
JAN042m1
Form GW-la
Rev 2/09