385890_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# 2010-00170
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)_
3 WELL USE (Check Applicable Box) Residential Water Supply Le
DATE DRILLED 05-24-10
TIME COMPLETED 3:00 AM 0 PM
4. WELL LOCATION:
CITY LEICESTER COUNTY BUNCOMBE
28 CODY BRIAN ROAD LEICESTER.NC
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑ Slope ['Valley ❑Flat ❑ Ridge ❑Other
LATITUDE 36 ° 35 59,807 0000 " DMS OR 3x xxxxxxxxx DD
LONGITUDE 75 ° 82 • 68,894 0000 " DMS OR 7x XXXXXXXXX DD
Latitude/longitude source DTopographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL OWNER
ROBERT HENSLEY
Owner Name
28 CODY BRIAN DRIVE
Street Address
LEICESTER
NC
City or Town State Zip Code
(828 ) 684-4874
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 145 FT
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO ge
c WATER LEVEL Below Top of Casing 20 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) 20 METHOD OF TEST RIG
f DISINFECTION* Type PILLS Amount 10
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 100 Ft 6 1 /4 #21 PVC
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Material
Top 0 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 Formation Descnption
+1 / 100 OVER BURDEN
100 / 145 FT GRANITE
/
/
/
JI lam
2 7 2010
12 REMARKS Information
Proc,cas
O WQ/E3 in9 Unit
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS tCORD HAS BEEN
PROVIDED TO THE WELL OWNER
120 [/ l✓ l �i���� J�/i%,r�/, — 06-11-2010
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
DERRICK HEATH SAWYERS
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processirt
1617 Mail Service Center, Raleigh, NC 27699-161, Phone [phone] g9
Form GW-la
Rev 2/09
JAN 1 1 2013