389805_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
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 80 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# 2010-00379 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 J[f
DATE DRILLED 10-29-10
TIME COMPLETED 4 30 AM ❑ PM El
4 WELL LOCATION
CITY candler COUNTY buncombe
64 OLD JOSH CREEK DRIVE 28715
(Street Name, Numbers Community Subdivision Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑ Slope ❑Valley ❑Flat ❑Ridge ❑Other_
LATITUDE 36 ° 30 . 5 531 0000" DMS OR 3x XXXXXXXXX DD
LONGITUDE 82 ° 45 2,022 0000 " DMS OR 7X XXXXXXXXX DD
Latitude/longitude source WISPS[Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5 WELL OWNER
CLAYTON HOMES
Owner Name
1123 SMOKY PARK HWY
Street Address
CANDLER
City or Town
828 ) 667-2529
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 390
9 SCREEN Depth Diameter Slot Size Material
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 Formation Description
0 /80 OVER BURDEN
80 /390 GRANITE
/
DEr 9 Into
NC 28715 / Information Prncessincl Unit
State Zip Code / DWQ/BOG
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO LEI
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 variance in accordance with 15A NCAC 2C 0118
e YIELD (gpm) 100 METHOD OF TEST RIG
f DISINFECTION Type PILLS Amount 18
/
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
iivt 7/12,124,
SIGNATURETUREOF CERTIFIED W L CONTRACTOR DATE
DERRICK HEATH SAWYERS
10-29-10
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]
Form GW-la
Rev 2/09
Tn xS
FEB 1 5 2013