381423_Well Construction - GW1_20100101

RESIDENTIAL WELL CONSTRUCTION R (Iiur
North Carolma Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3172 OCT o Z110
1 WELL CONTRACTOR
Everard Baker Jordan
Well Contractor (Individual) Name
Jordan Environmental. LLC
Well Contractor Company Name
68 Little Horse Road
Street Address
Waynesville
City or Town
( 828) 734-2612
NC 28786
State Zip Code
g WATER ZONES (depth)
Top 65 0 Bottom 71 5 Top
Top Bottom Top
Top Bottom Top
7 CASING Depth Diameter
Top 0 0 Bottom 51 5 Ft 2
Top Bottom Ft
Top Bottom Ft
Area code Phone number 8 GROUT Depth Material
2 WELL INFORMATION Top 0 0 Bottom 48 5 Ft Portland
WELL CONSTRUCTION PERMIT# Top Bottom Ft
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) MW- 1
3 WELL USE (Check Applicable Box) Residential Water Supply ❑
DATE DRILLED 2/12/10
TIME COMPLETED 1700 AM 0 PM [f
4 WELL LOCATION
CITY Asheville COUNTY Buncombe
11 Hibriten Drive
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropnate box)
VSlope ❑ Valley ❑ Flat ❑ Ridge ❑ Other
LATITUDE 36 " DMS OR 35 608197 DD
LONGITUDE 75 " DMS OR 82 573633 DD
Latitude/longitude source [GPS [Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5 WELL OWNER
Janet Cope
Owner Name
11 Hlbrlten Drive
Street Address
Asheville NC 28786
City or Town State Zip Code
(828 ) 251-9360
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 71 5
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO d
c WATER LEVEL Below Top of Casing 65 0 FT
(Use "+" if Above Top of Casing)
d TOP OF CASING IS 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)
METHOD OF TEST
f DISINFECTION Type
Amount
Top 51 5
Top
Top
Top Bottom Ft
Bottom
Bottom
Bottom
Thickness/
Weight Matenal
sch40 PVC
Method
Tremmie
9 SCREEN Depth Diameter Slot Size Material
Bottom 71 5 Ft 2 in 10 in PVC
Ft in in
Ft in in
Bottom
Bottom
10 SAND/GRAVEL PACK
Depth Size Material
Top 49 5 Bottom 71 5 Ft 2 Sand
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
00 / 1 1 0
110 /715
/
/
12 REMARKS
Formation Descnption
orange silty sand
brown sandy silt
f
IVIAK 2 2010
\NATEk UUht-t i ►'U
tntonn-Paon Prncesstng Unit
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THA+PY OF 1 RECORD HAS BEEN
PROVIDED TE NE
SI NATUR
Everard Baker Jor.an
2/24/10
LL CONTRACTOR DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
NI 0
Submit within 30 days of completion to. Division of Water Quality -
1617 Mail Service Center, Raleigh, NC 27699-161, Phone [phone]
Information Processing,
Form GW-la
Rev 2/09