385891_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#
NC 28743
State Zip Code
OTHER ASSOCIATED PERMIT#(rf applicable)
SITE WELL ID #(if applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply lRf
DATE DRILLED 06-03-2010
TIME COMPLETED 2:00 AM ❑ PM II
4 WELL LOCATION.
CITY LEICESTER couNTY BUNCOMBE
MOORES VALLEY ROAD LEICESTER NG
(Street Name, Numbers, Community, Subdivision, Lot No Parcel Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑Slope GiValley ❑ FIat DRidge ❑Other
LATITUDE 36 ° 35 • 62,121 0000 ° DMS OR 3x xxxxxxxxx DD
LONGITUDE 75
82 ' 69 257 0000 " DMS OR 7X xxxxxxxxx DD
Latitude/longitude source VGPS [(Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL OWNER
KELLY DALMAS
Owner Name
MOORES VALLEY ROAD
Street Address
LEICESTER
LEICESTER.NC
NC
City or Town
(828 ) 279-3213
Area code Phone number
6 WELL DETAILS:
a TOTAL DEPTH 245 FT
State Zip Code
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c WATER LEVEL Below Top of Casing 40 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 12
/S91
g WATER ZONES (depth)
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
7 CASING Depth Diameter
Top +1 Bottom 160 Ft 6 1/4
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Material
Top 0 Bottom 20 Ft CEMENT
Top Bottom Ft
Top Bottom Ft
Thickness/
Weight Material
#21 PVC
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
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
+1 /160
160 /245 FT
12 REMARKS
Size Material
Formation Descnption
OVER BURDEN
GRANITE
/Worn -whorl
D WQiRQ^ss0rtQ 1 /n:t
2010
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
PROVI D TO THE WELL OWNER j
/
SIGNATURE OF CERTIFIED WELL CONTRAC7FOR DATE
DERRICK HEATH SAWYERS
PRINTED NAME OF PERSON CONS
Submit within 30 days of completion to. Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone • [phone]
THE WELL
JAN 1 1 2013
Form GW-la
Rev 2/09