387455_Well Construction - GW1_20100101

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of hnvironntLnt and Natural Resources- 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
c
d
e
g WATER ZONES (depth)
Top 0 Bottom 125 Top
Top Bottom Top
Top Bottom Top
7 CASING Depth Diameter
Top 0 Bottom 86 Ft 6 1/4"
NC 28748 Top Bottom Ft
City or Town State Zip Code
Top Bottom Ft
( 828) 683-9223
Area code Phone number 8 GROUT Depth Material
2 WELL INFORMATION Top 0 Bottom 21 Ft Concrete
WELL CONSTRUCTION PERMIT# 2010-00075 Top Bottom Ft
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply
DATE DRILLED 4/12/2010
TIME COMPLETED AM ❑ PM ❑
4 WELL LOCATION
CITY Fairview COUNTY Buncombe
Cheston Mtn Rd Lot# 22
(Street Name Numbers Community Subdivision Lot No Parcel Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropriate box)
GXSlope ❑Valley ❑Flat ❑Ridge ❑OthereleV 2095
LATITUDE 35 ° 32 • 629 0000 " DMS OR 3x xxxxxxxxx DD
LONGITUDE 82 ° 27 643 0000 " DMS OR 7x XXXXXXXXX DD
Latitude/longitude source (Ps DTopographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5 WELL OWNER
Richard R Webb(%America's Home Place
Owner Name
462 Weaverville Hwv
Street Address
Asheville NC 28804
City or Town State Zip Code
(828 ) 658-0402
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 305'
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO g
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 variance in accordance with 15A NCAC 2C 0118
YIELD (gpm) 5 METHOD OF TEST Gal Contain
DISINFECTION Type Tablet Amount 2
Top Bottom Ft
3.,
Bottom
Bottom
Bottom
Thickness/
Weight Material
SDR2 PVC
Method
Pour
9 SCREEN Depth Diameter Slot Size Material
Mf. Top Bottom Ft in in
Top Bottom Ft in in
Top Bottom Ft in in
10 SAND/GRAVEL PACK
Depth Size Material
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
12 REMARKS
Formation Description
•`,tP 14 2010
If if lrr°Yc>ii„Y`= ,,rx+Lq e
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
4/16/2010
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
Chad Surrett
PRINTED NAME OF PERSON CONSTRUCTIN
Submit within 30 days of completion to Division of Water Quality - 'Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone [phone]
JANQ7
19.
GW-la
vJ 2/09