388963_Well Construction - GW1_20100101

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3282
1 WELL CONTRACTOR
Gerald Sisemore
Well Contractor (Individual) Name
Greene Bros Well & Pump, WT Inc
Well Contractor Company Name
STREET ADDRESS PO Box 724 61 New Clyde Hwy
Canton NC 28716
City or Town State
( 828 )_ 648-3170
Zip Code
Area code- Phone number
2 WELL INFORMATION
SITE WELL ID #(if applicable)
WELL CONSTRUCTION PERMIT# 2009-01310
OTHER ASSOCIATED PERMIT#(if applicable)
3 WELL USE (Check Applicable Box) Residential
DATE DRILLED 10/21/10
Water Supply 4c
0 PM 0
Buncombe
TIME COMPLETED AM
4 WELL LOCATION
CITY Leicester CouNTY
Newfound/Brookshire/Leicester Hwy/Herringbone Dr
(Street Name Numbers, Community Subdivision Lot No Parcel Zip Code)
TOPOGRAPHIC / LAND SETTING
0 Slope 0 Valley 0 Flat IX Ridge 0 Other
(check appropnate box)
LATITUDE 3 5 655N
May be in degrees,
minutes, seconds or
in a decimal format
LONGITUDE 8 2 696W
Latitude/longitude source 0 GPS X Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
5 WELL OWNER
OWNER'S NAME Kevin King
ST EET ADDRESS -Pt',(q / //0p
r At.a. Z NC A874‘e9
D •
City or Town State
( 828 )_ 777-1083
Zip Code
YES 0 NOB
FT
Area code - Phone number
6 WELL DETAILS
a TOTAL DEPTH 125
b DOES WELL REPLACE EXISTING WELL?
c WATER LEVEL Below Top of Casing 60
(Use "+" if Above Top of Casing)
d TOP OF CASING IS 1 FT Above
Land Surface*
surface may require
2C 0118
TEST 2 hours
*Top of casing terminated at/or below land
a variance in accordance with 15A NCAC
e YIELD (gpm) 20 METHOD OF
338963
f DISINFECTION Type HTH Amount 22 tabs
g WATER ZONES (depth)
From 0 To 65 From 65 To 85
From To From To
From To From To
7 CASING Thickness/
Depth Diameter Weight Material
From O To 60 Ft 6" PVC
From To Ft
From To Ft
8 GROUT Depth Material Method
From 0 To 20 Ft cement to toD
From To Ft
From To Ft
9 SCREEN Depth Diameter Slot Size Material
From To Ft in in
From To Ft in in
From To Ft in in
10 SAND/GRAVEL PACK
Depth Size Material
From To Ft
From To Ft
From To Ft
11 DRILLING LOG
From To Formation Description
0 60 clay
60 125 granite
�.
.i e, 0 f)6A1.
JP IN f ""
12 REMARKS
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
10/21/10
S GNATURE OF CEIRVEtWELL CONTRACTOR DATE
Gerald Sizemore
PRINTED NAME OFiiPERSON-CONST) UC�TII-NG THE WELL
NOV 0 4 2010
(iifgrrnatrn-
Submit the original to the Division of Water Quality within 30 days Attn Information(Mgt ;,I,g 1Jn'1
1617 Mad Service Center— Raleigh, NC 27699-1617 Phone No [phone] ext 568 0/Si lG
Form GW-la
Rev 3/07