385886_Well Construction - GW1_20100101

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 DRILLINd
Well Contractor Company Name
14885 HWY 209
Street Address
HOT SPRINGS. NC 28743
City or Town
( 828) 665-2022
Area code Phone number
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT# 2010 00244
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply itf
DATE DRILLED 6-4-10
TIME COMPLETED 4'00 AM ❑ PM [Ni
4 WELL LOCATION
cnTY BLACK MTN couNTY BUNCOMBE
34 HAVENS CREEK ROAD 28711
(Street Name, Numbers Community, Subdivision, Lot No Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropnate box)
ESlope ❑ Valley ❑ Flat ❑ Ridge ❑Other
LATITUDE 35 ° 52 964 0000 " DMS OR 3x xxxxxxxxx DD
LONGITUDE 82 ° 24 , 953 0000 " DMS OR 7x xxxxxxxxx DD
Latitude/longitude source G7f3PS :Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5 WELL OWNER
AMANDA VON ROEKEL
Owner Name
34 HAVENS CREEK ROAD
Street Address
BLACK MTN
City or Town
(828 ) 273-2511
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 125
NC 28711
State Zip Code
b DOES WELL REPLACE EXISTING WELL/ YES ❑ NO C�
c WATER LEVEL Below Top of Casing 30 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) 50 METHOD OF TEST RIG
f DISINFECTION Type PILLS Amount 12
g WATER ZONES (depth)
Top Bottom Top
Top Bottom Top
Top Bottom Top
7 CASING Depth Diameter
3r.,5886
Bottom
Bottom
Bottom
Thickness/
Weight Material
Top 0 Bottom 82 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
Top Bottom
10 SAND/GRAVEL PACK'
Depth
Top Bottom
Top Bottom
Top Bottom
11 DRILLING LOG
Top Bottom
0 /82
82 /125
/
/
/ Information Nroc
/ DWQ �'Ni9 Unit
Ft in in
Ft in in
Ft
Ft
Ft
Size Material
Formation Description
OVER BURDEN
GRANITE
12 REMARKS
JUI 2 7 20i0
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
tiiLwi.e�
SIGNATURE OF CE TIFIED WELL CONT
DERRICK HEATH SAWYERS
Q 64-10
CTOR DATE
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] Rev z/09
Tm SForm GW-1a
J AN 1 1 2013