388712_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 State Zip Code
( 828 ) 665-2022
Area code Phone number
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(dapplicable)
SITE WELL ID #(if applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply MJf
DATE DRILLED 06-21-2010
TIME COMPLETED 4.00 AM 0 PM Li
4 WELL LOCATION
cITY WEAVERVILLE COUNTY BUNCOMBE
Cherry Ridae Estates Lot # 9 Weaverville N6
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zp Code)
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑ Slope Walley ❑ Flat ❑ Ridge ❑ Other
LATITUDE 35
LONGITUDE 82
75,257 0000 „ DMS OR 3x XXXXXXXXX DD
56,715 0000 „ DMS OR 7x XXXXXXXXX DD
Latitude/longitude source litPS Oropographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5 WELL OWNER
STEWART ACQUISITION
Owner Name
LOT # 9 CHERRY RIDGE ESTATES
Street Address
WEAVERVILLE NC
City or Town State Zip Code
( 828-) 279-0171
Area code Phone number
6 WELL DETAILS
a. TOTAL DEPTH 405
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO t '
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) 3 METHOD OF TEST RIG
DISINFECTION Type PILLS Amount 20
9
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7 CASING Depth Diameter Weight Material
3
:)
WATER ZONES (depth)
Top +1 Bottom 120 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
Top Bottom Ft in
Top Bottom Ft in
Top Bottom Ft in
Slot Size Material
m
in
m
10 SAND/GRAVEL PACK
Depth Size Material
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom Formation Descnption
1 FT / 120 OVER BURDEN
120 /405 GRANITE
12 REMARKS
Nfl\/ fE 9 7nln
Information Fiocsssing Unit
DWG/BOG
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-,,2ca $ 10-18-2010
SIGNATURE OF CERTIFIED WELL CONCTOR 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]
SForm GW-la
Rev 2/09
JAN 0 4 201E