380770_Well Construction - GW1_20100101

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3782
1 WELL CONTRACTOR
Gerald Sizemore
Well Contractor (Individual) Name
Greene Bros Well & Pump WT Inc
Well Contractor Company Name
STREET ADDRESS 61 New Clyde Hwy
Canton NC 28716
City or Town State
( 828 )_ 648-3170
Zip Code
Area code- Phone number
2 WELL INFORMATION
SITE WELL ID #(if applicable)
WELL CONSTRUCTION PERMIT# 2009-00657 (Drilled deeper)
OTHER ASSOCIATED PERMIT#(if applicable)
3 WELL USE (Check Applicable Box) Residential
DATE DRILLED 1/14/10
Water Supply IX
0 PM 0
Buncombe
TIME COMPLETED AM
4 WELL LOCATION
CITY Candler COUNTY
Pete Luther Rd/74 Wilderness Trail
(Street Name Numbers, Community Subdivision Lot No Parcel Zip Code)
TOPOGRAPHIC / LAND SETTING
0 Slope O Valley O Flat 0 Ridge 1 Other Ridge
(check appropriate box)
LATITUDE 3 5 548N
May be in degrees,
minutes seconds or
in a decimal format
LONGITUDE 8 2 651W
Latitude/longitude source 0 GPS X Topographtc map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
5 WELL OWNER
OWNER'S NAME Kenneth Owenby
STREET ADDRESS PO Box 1518
Enka NC 28728
City or Town State
( 828 )_ 665-9205
Zip Code
cal -aid
YESO NOR
FT
Area code - Phone number
S
6 WELL DETAILi
a TOTAL DEPTH 605 (Set up on 35D-
b DOES WELL REPLACE EXISTING WELL?
c WATER LEVEL Below Top of Casing
(Use "+" if Above Top of Casing)
d TOP OF CASING IS 1 FT Above
Land Surface*
surface may require
2C 0118
TEST 2 hours
*Top of casing terminated at/or below land
a variance in accordance with 15A NCAC
e YIELD (gpm) 7 METHOD OF
380770
f DISINFECTION Type HTH Amount 109 tabs
g WATER ZONES (depth)
From 500 To 555 From To
From To From To
From To From To
7 CASING Thickness/
Depth Diameter Weight Material
From To Ft
From To Ft
From To Ft
8 GROUT Depth Material Method
From To Ft
From To Ft
From To Ft
9 SCREEN Depth Diameter Slot Size Material
From To Ft in in
From To Ft in in
From To Ft in in
10 SAND/GRAVEL PACK
Depth Size Material
From To Ft
From To Ft
From To Ft
11 DRILLING LOG
From To Formation Description
350 605 Drilled 255'
REGEWED
FEB 0 5 ili10
►ntormatlon Piol.ig Unit
UWu/EsOit,
12 REMARKS
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A N AC 2C WELL CONSTRUCTION STANDARDS AND THAT A COPY OF THIS
REC D HAS BEEN PRO ED,TO THE WELL OWNER
1/18/10
SIGNATURE 0 FED WELL CONTRACTOR DATE
Gerald Sizemore
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 der
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No (919)
nformation Mgt ,
`Jil .b
t 568
Form GW-la
Rev 3/07
FEB 072013