385884_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 NC 28743
City or Town
( 828) 665-2022
Area code Phone number
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT# BUNG 2010-00309
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply d
DATE DRILLED 5-28-10
TIME COMPLETED 4:00 AM ❑ PM Ni
4 WELL LOCATION
cITY BARNARDSVILLE COUNTY BUNCOMBE
NORTH FORK ROAD
(Street Name, Numbers, Community, Subdivision, Lot No Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropriate box)
❑Slope :Walley ❑ Flat ❑ Ridge ['Other
LATITUDE 35 ° 78 684 0000 " DMS OR 3x XXXXXXXXX DD
LONGITUDE 82 ° 82 41,3940000 DMS OR 7x XXXXXXXXX DD
Latitude/longitude source E 3PS [Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5 WELL OWNER
KIMBERLY BUCKNER
Owner Name
PO BOX 1070
Street Address
ENKA NC 28728
City or Town State Zip Code
(828 ) 777-9411
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 325
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO LEI
c WATER LEVEL Below Top of Casing 120 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) 5 METHOD OF TEST RIG
f DISINFECTION Type PILLS Amount 15
3r 8 84
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 35 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
0 /35
Formation Description
OVER BURDEN
35 / 125 GRANITE
/
l NA k.r17"1oI
JUL 2 7 ?n,o
liirormation Processing Unit
12 REMARKS DWQ/BO
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
1:Witsu-Ck_ 'l �QC�i� �TO 5-28-10
SIGNATURE OF CERTIFIED WELL CO RACTOR DATE
DERRICK HEATH SAWYERS
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing, i ' ,'*
AN 072013
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-la
Rev 2/09