388714_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# 2009-00150
NC 28743
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply LJf
DATE DRILLED 10-01-2010
TIME COMPLETED 3.00 AM 0 PM Ly
4 WELL LOCATION
CITY fairview COUNTY buncombe
wrlahts cove road
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑Slope iIValley ❑ Flat ❑ Ridge ❑ Other
LATITUDE 35 i 54 179 0000 DMS OR 3x XXXXXXXXX DD
LONGITUDE 82 i 40,536 0000 " DMS OR 7x XXXXXXXXX DD
Latitude/longitude source EGPS ❑Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5 WELL OWNER
James B. Cook
Owner Name
wrlahts cove rd
Street Address
fairview
City or Town
(828 ) 628-0280
Area code Phone number
6 WELL DETAILS'
a TOTAL DEPTH 525
nc 28730
State Zip Code
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO IR(
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) 1 METHOD OF TEST RIG
f. DISINFECTION Type PILLS Amount 20
g WATER ZONES (depth)
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7 CASING Depth Diameter Weight Material
Top +1 Bottom 54 Ft 6 25" #21 PVC
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Material Method
Top 0 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
Formation Descnption
1 /54 OVER BURDEN
54 / 525 GRANITE
/
12 REMARKS
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I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS D THAT A COPY OF THIS RECOR �. AS BEEN
PROVIDED O HE WELL OWNER
SIGNA
URE OF CERTIFIED W
LL CONTRACTOR d DATE
DERRICK HEATH SAWYERS
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Process
1617 Mail Service Center, Raleigh, NC 27699-161, Phone . [phone]
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Form GW-la
Rev 2/09