387365_Well Construction - GW1_20100914

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
Well Contractor (Individual) Name
CLYDE SAWYERS AND SON WELL DRILL
Well Contractor Company Name
14885 HWY 209
Street Address
HOT SPRINGS NC 28743
City or Town State Zip Code
( 828) 665-2022
Area code Phone number
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT# 2010-00300
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply (tti
DATE DRILLED 08-04-2010
TIME COMPLETED 1 1 00 AM IV PM ❑
4 WELL LOCATION
cm( WEAVERVILLE CouNTY BUNCOMBE
201 NEW COVENANT WEAVERVILLE NC
(Street Name Numbers Community Subdivision Lot No Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑Slope ❑Flat ❑ Ridge ❑Other
LATITUDE 35 , 72 091 0000 „ DMS OR 3x XXXXXXXXX DD
LONGITUDE 82 56 526 0000 " DMS OR 7x XXXXXXXXX DD
Latitude/longitude source RIPS ['Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5 WELL OWNER
GENEVA SUMNER
Owner Name
201 NEW COVENANT DRIVE
Street Address
WEAVERVILLE
NC
City or Town
828 ) 319-9646
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 285
State Zip Code
b DOES WELL REPLACE EXISTING WELL? YES CAI NO ❑
c WATER LEVEL Below Top of Casing 40 FT 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 vanance in accordance with 15A NCAC 2C 0118
e YIELD (gpm) 3 METHOD OF TEST RIG
f DISINFECTION Type PILLS Amount 12
ct'
g WATER ZONES (depth)
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness)
7 CASING Depth Diameter Weight Material
Top 0 Bottom 79 Ft 6 25" #21 PVC
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Material
Top O Bottom 20 Ft CEMENT
Top Bottom Ft
Top Bottom Ft
Method
POURED
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
+1 /79 OVER BURDEN
79 /285 GRANITE
/
12 REMARKS
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I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STAND QS, AND THAT A COPY OF THIS REC!J'' D HAS BEEN
PROVIDED TO THE WELL OWN
�j��g1� QCG08-18-2010
IGNATURE OF ERTIF D ELL CONTRAC- DATE
e/2P e`C . / Cc.
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