388709_Well Construction - GW1_20100101

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
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
nc 28743
State Zip Code
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# 2010-00177
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(i( applicable)_
3 WELL USE (Check Applicable Box) Residential Water Supply iS
DATE DRILLED 9-8-2010
TIME COMPLETED 4:00
AM ❑ PM((
4. WELL LOCATION.
CITY candler COUNTY buncombe
4 Breezv Pine Lane 28715
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑ Slope ❑Valley ❑ FIat ❑ Ridge ❑Other
LATITUDE 35 ° 29 • 581 0000 " DMS OR 3x XXXxXxxXX DD
LONGITUDE 82 ° 44 8,546 0000 DMS OR 7x.xxxxxxxxx DD
Latitude/longitude source PS Dropographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5 WELL OWNER
Scott Gosnell
Owner Name
4 Breezv Pine Lane
Street Address
Candler NC 28715
City or Town State Zip Code
(828 ) 318-7937
Area code Phone number
6 WELL DETAILS:
a. TOTAL DEPTH: 185
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO pc
c. WATER LEVEL Below Top of Casing 40 FT FT
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS 1 FT 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) 50 METHOD OF TEST RIG
f. DISINFECTION Type pills Amount 18
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 103 Ft 6 25" #21 PVC
Top Bottom Ft
Top Bottom Ft
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 Formation Descnption
0 /103 OVER BURDEN
103 /185 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, AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER
f)1Lz31.1:..7& 9-8-10
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SIGNATURE OF CERTIFIED WELRA 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,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone . [phone]
Form GW-la
Rev 2/09
JAN ®4 2C