383609_Well Construction - GW1_20100101

May 14 10 11 13a Scott Gantt
7044347212
p1
1 WELL CONTRACTOR
ALAN S GANTT
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Fnvrronmcnt and Nrtural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2584A
Well Contractor (Indrvidual) Name
CAROLINA WELL DRILLERS INC
Well Contractor Company Name
522 GANTTS GROVE CH RD
Street Address
MOORESBORO NC 28114
City or Town State Zip Code
( 704) 434-7277
Area code Phone number
2 WELL INFORMATION
WELL CONSTRUCTION PERMITS 2009-00255
OTHER ASSOCIATED PERMIT#(ifapplicable)
SITE WELL ID Cif applirzble'
3 WELL USE (Check Applicable Box) Residential Water Supply 0
DATE DRILLED 4/16/10
TIME COMPLETED 10 AM El( PM
4 WELL LOCATION
CITY BLACK MOUNTAIN couNTYBUNOCMB6
59 OLD APPLE WAGON RD,
,Street Name Numbers Commr.mty St.bdrvision _ot No Parcel Zp Code)
TOPOGRAPHIC / LAND SETTING (uieek appropriate box)
❑Slope ❑Valley °Flat °Ridge ❑Other
LATITUDE _ 35 - 28 , 468.0000 * DMS OR 3x xxxxxxxxx DD
LONGITUDE 82 . 14 • 438 0000 - DMS OR 7x xxxxxxxxx uo
Latitude/longitude source lit PS DTopographic map
(location of wefl must be shown on a USGS topo map andattached to
th:s form if not using GPS)
6 WELL OWNER
MELINDA STAFFORD
Owner Narne
888 Bee Tree RD #4
Street Address
Swannoa NC n778
City or Town State Zip Code
( 828) 989-7166
Area code Phone number
6 WELL DETAILS.
a TOTAL DEPTH 440
b DOES WELL REPLACE EXISTING WELL', YES° NO (
c WATER LEVEL Below Top of Casing 51 FT
(Use -+ if Above Top of Casing)
d TOP OF CASING IS 1 5 FT Above Land Surface'
'Top of casing terminated aUor below land surface may require
a variance m accordance with 15A NCAC 2C 0118
e YIELD (gpm) 1 METHoo OF TEsTARDM
f DISINFECTION Type HYPOCHL Amount 20 OZ
g WATER ZONES (depth)
Top 344 Bottom 345 Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness)
7 CASING Depth Diameter Weight Material
Top+1 5 Bottom 98 Ft 6 1/8 SDR21 PVC
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Material
Top 0 Bottom-6 Ft GRAVEL MIX
Top-6 Bottom-20 Ft HOLE PLUG
Top Bottom Ft
Method
GRAVITY
GRAVITY
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 IZ
Top Bottom R
11 DRILLING LOG
Top Bottom
0 /91
Size Material
Formation Description
CLAY
91 /440 CONSOLIDATED ROCK
/
/
/
►v►Ar142010
Intorfnatwn Pror s.qi ,3 zi.
/ DWOJBOG
12 REMARKS
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
4f21/10
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
ALAN S GANTT
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to Division of Water Quality - lnfarmatt rot tng,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone [phone]
0y o�!/!A�
Form GW-1 a
Rev 2/09
JAN 1 5 2013