386444_Well Construction - GW1_20100819

RESIDENTIAL WELL CONSTRUCTION RECORD
ELC
North Carolina Department of Environment and Natural Resources- Division of Water Qualrt'yuu 3 1 20
WELL CONTRACTOR CERTIFICATION # 4022-A
1 WELL CONTRACTOR
DERRICK SCOTT LEDFORD
Well Contractor (Individual) Name
CLYDE SAWYERS AND SON WELL DRILL
Well Contractor Company Name
14885 HWY 209
Street Address
HOT SPRINGS
City or Town
828 ) 665-2022
Area code Phone number
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT#
NC 28743
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply f�
DATE DRILLED 08-05-2010
TIME COMPLETED 1 00 AM ❑ PM 125(
4 WELL LOCATION
cm, LEICESTER COUNTY BUNCOMBE
BEAR WALLOW TRAIL LEICESTER NC
(Street Name Numbers Community, Subdivision Lot No Parcel Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropnate box)
I'Slope EValley ❑ Flat ❑ Ridge ❑Other
LATITUDE 35 . 58 676 0000 DMS OR 3x XXXXxxxxx DD
LONGITUDE 82 . n 486 0000 " DMS OR 7x XXXXxxxxx DD
Latitude/longitude source likPS Qropographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5 WELL OWNER
THOMAS VESSER
Owner Name
BEAR WALLOW TRAIL
Street Address
LEICESTER
NC
City or Town
828 ) 280-1924
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 405
State Zip Code
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO iqf
c WATER LEVEL Below Top of Casing 60 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 variance in accordance with 15A NCAC 2C 0118
e YIELD (gpm) 2 METHOD OF TEST RIG
f DISINFECTION Type PILLS Amount 25
g WATER ZONES (depth)
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7 CASING Depth Diameter Weight Material
Top O Bottom 73 Ft 6 25" 21 PVC
Top Bottom Ft
Top Bottom Ft
4 /!
8 GROUT Depth Material Method
Top O Bottom 20 Ft CEMENT POURED
Top Bottom Ft
Top Bottom Ft
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
+1 /73
73 /405
12 REMARKS
Formation Description
OVER BURDEN
GRANITE
AUG 1 A 7(11(1
infr,rmation Processing Unit
DWQ/BOG
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
08-12-2010
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
DERRICK SCOTT LEDFORD
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