388711_Well Construction - GW1_20100101

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 4022-A
1 WELL CONTRACTOR
DERRICK SCOTT LEDFORD
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# 2010-00784
NC 28743
State Zip Code
OTHER ASSOCIATED PERMIT#(rf applicable)
SITE WELL ID #(if applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply JCf
DATE DRILLED 08-09-2010
TIME COMPLETED 12.30 AM 0 PM (Y
4 WELL LOCATION
cITY WEAVERVILLE COUNTY BUNCOMBE
33 WILLIE LANE WEAVERVILLE . NC
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑ Slope t 'Valley ❑ Flat ❑ Ridge ❑Other
LATITUDE 35 ' 7793990000" DMS OR 3x XXXXXXXXX DD
LONGITUDE 82
518 181 0000 " DMS OR 7x XXXXXXXXX DD
Latitude/longitude source Wit PS Ofopographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5 WELL OWNER
JEFF AND TAMMY CALLAHAN
Owner Name
33 WILLIE LANE
Street Address
WEAVERVILLE
NC
City or Town
( 828 ) 279-0171
Area code Phone number
6 WELL DETAILS.
a TOTAL DEPTH: 365 FT
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO pf
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
f DISINFECTION Type PILLS Amount 15
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 FT Bottom 80 Ft 6 25" #21 PVC
Top Bottom
Top Bottom
Ft
Ft
8 GROUT Depth Material
Top O Bottom 20 Ft CEMENT
Top Bottom
Top Bottom
Ft
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
+1 /80
80 / 365 FT
/
/
12 REMARKS
Formation Descnption
OVER BURDEN
GRANITE
e rr R" 1+ A' 17" If—
!R V Ls Li
NUV U G LUIU
Information i1iocessing unit
vvv1/4.4UD Jv
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
, 4Rr�10-15-2010
SIGNATURE OF CE IFIED WELL N RACTOR DATE
DERRICK SCOTT LEDFORD
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to. Division of Water Quality - Information Processi
1617 Mail Service Center, Raleigh, NC 27699-161, Phone [phone]
0420e
Form GW-la
Rev 2/09