389803_Well Construction - GW1_20101201

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
3t c
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 Bottom 91 Ft 6 25" #21 PVC
HOT SPRINGS NC 28743 Top Bottom Ft
City or Town State Zip Code Top Bottom Ft
( 828) 665-2022
Area code Phone number 8 GROUT Depth Material Method
2 WELL INFORMATION Top 0 Bottom 20 Ft CEMENT POURED
WELL CONSTRUCTION PERMIT# 2010-00530 Top Bottom Ft
OTHER ASSOCIATED PERMIT#(if applicable) Top Bottom Ft
SITE WELL ID #(if applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply le
DATE DRILLED 10-19-2010
TIME COMPLETED 4 00 AM ❑ PM NI
4 WELL LOCATION 10 SAND/GRAVEL PACK
CITY SWANNANOA COUNTY BUNCOMBE Depth Size Material
Top Bottom Ft
9 SCREEN Depth Diameter Slot Size Material
Top Bottom Ft m in
Top Bottom Ft in in
Top Bottom Ft in in
70 OLD BEE TREE RD SWANNANOA Top Bottom Ft
(Street Name Numbers Community, Subdivision, Lot No Parcel Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑Slope ticValley ❑Flat itTRidge ❑Other
LATITUDE 35 ' 61696020000„ DMS OR 3x XXXXXXXXX DD
LONGITUDE 82 ° i 43462410000 DMS OR 7x XXXXXXXXX DD
Top Bottom Ft
11 DRILLING LOG
Top Bottom Formation Description
0 /91 FT OVER BURDEN
Latitude/longitude source [3PS [Topographic map 91 FT / 505 FT GRANITE
(location of well must be shown on a USGS topo map andattached to /
this form if not using GPS) /
5 WELL OWNER /
FRAIZER MORROW /
/
Owner Name / .® E , Ii• I \ i
70 OLD BEE TREE RD SWANNANOA
Street Address
SWANNANOA NC / DEC, G . 201(!
City or Town State Zip Code ( 502 ) 558-2532
/
/ Information Yra os3ts'9 IndU
Area code Phone number dd��
12 REMARKS
6 WELL DETAILS
a TOTAL DEPTH 505 FT
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO Cie
c WATER LEVEL Below Top of Casing 60 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 variance in accordance with 15A NCAC 2C 0118
e YIELD (gpm) 1 METHOD OF TEST RIG
f DISINFECTION Type PILLS Amount 15
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
SIGNATURE OF CERT1FrED WELL CONTRACTOR
DERRICK HEATH SAWYERS
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone [phone]
FEB 152013
rm GW-la
2/09