385883_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 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# 2006-01211
NC 2873
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply [j '
DATE DRILLED 06-30-2010
TIME COMPLETED 3 00 AM ❑ PM El
4. WELL LOCATION
cITY FAIRVIEW couNTY BUNCOMBE
BRIAR RIDGE
(Street Name, Numbers, Community Subdivision, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑Slope It/alley ❑Flat ❑Ridge El Other
LATITUDE 35 ' 50713440000DMS OR 3x XXXXXXXxx DD
LONGITUDE 82 ' '9719790000 ,. DMS OR 7x xxxxxxxxx DD
Latitude/longitude source 5kPS [Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5 WELL OWNER
CHRISTOPHER CORNETT
Owner Name
BRIAR RIDGE
Street Address
FAIRVIEW NC 28730
City or Town State Zip Code
(828 ) 243-8779
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 705
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO rgr
c WATER LEVEL Below Top of Casing 200 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) 1 METHOD OF TEST RIG
f DISINFECTION. Type PILLS Amount 25
g WATER ZONES (depth)
Top Bottom
Top
Top
Bottom
Bottom
3 ( 5 S 8 t 3
Top Bottom
Top Bottom
Top Bottom
Thickness/
7 CASING Depth Diameter Weight
Top 1 Bottom 120 Ft 6 1 /4 21
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Material
Top O Bottom 20 Ft CEMENT
Top Bottom Ft
Top Bottom Ft
Material
PVC
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
1 /120
120 /705
/
Formation Descnption
OVER BURDEN
GRANITE
/
CE I \% D
/ JUL 2 1• 1010
12 REMARKS
Information Pro( &ss ng Untt
D WQ/RrtiC
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARD,$, AND THAT A COPY OF THIS R ORD HAS BEEN
PROVIDED.TO THE WELL OWNER
L-06-30-2010
SIG TURE OF CERTIFIED WELL CONTRAC 'OR DATE
DERRICK HEATH SAWYERS
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,TmS
1617 Mail Service Center, Raleigh, NC 27699-161, Phone • [phone]
Form GW-la
Rev 2/09
JAN 1 1 2013