390181_Well Construction - GW1_20101223

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
39918
g WATER ZONES (depth)
Top Bottom Top Bottom
Well Contractor (Individual) Name Top Bottom Top Bottom
CLYDE SAWYERS AND SON WELL DRILL Top Bottom Top Bottom
Well Contractor Company Name Thickness/
14885 HWY 209 7 CASING Depth Diameter Weight Material
Top +1 Bottom 21 Ft 6 25" #21 PVC
HOT SPRINGS NC 28743 Top Bottom Ft
City or Town State Zip Code Top Bottom Ft
( 828 ) 665-2022
Area code Phone number 8 GROUT Depth Material Method
2 WELL INFORMATION Top 0 Bottom 20 Ft CEMENT POURED
WELL CONSTRUCTION PERMIT# 2010-00465 Top Bottom Ft
OTHER ASSOCIATED PERMIT#(if applicable) Top Bottom Ft
Street Address
SITE WELL ID #(if applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply Wtr
DATE DRILLED 10-20-2010
TIME COMPLETED 4 00 AM 0 PM E
4 WELL LOCATION
cITY LEICESTER COUNTY BUNCOMBE
MOUNT SOMA BLVD LOT 208
(Street Name Numbers Community Subdivision Lot No Parcel Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑Slope ❑Valley ❑ Flat fiRidge ❑ Other
LATITUDE 35 , 66 876 0000 " DMS OR 3x xxxxxxXXx DD
LONGITUDE 82 ' 86 422 0000 " DMS OR 7x xxxxXXXxx DD
Latitude/longitude source [PS ['Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5 WELL OWNER
AUTUMN TRAILS . LLC
Owner Name
MT SOMA BLVD
Street Address
LEICESTER
City or Town
828 ) 712-9944
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 1005
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
0 /21FT
Formation Descnption
OVER BURDEN
21 FT / 1005 FT GRANITE
/ wiRcf—T:flQ /yrrt,
rr,-,
/ DEC 2010
NC 28746
State Zip Code
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO I '
c WATER LEVEL Below Top of Casing 100 FT FT
(Use "+" if Above Top of Casing)
d TOP OF CASING IS 1 FT FT Above Land Surface*
"Top of casing terminated aUor below land surface may require
a vanance in accordance with 15A NCAC 2C 0118
e YIELD (gpm) 1/2 METHOD OF TEST RIG
f DISINFECTION Type PILLS Amount 30
12 REMARKS
%NATE;-
inforrni-'ion r'rCitr G`.,i i Li.,
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RfyCORD HAS BEEN
PROVIra.1n TO THE WELL OWNE
SI
OF CER I IED WELL CONTRA OR DATE
010
DERRICK HEATH SAWYERS
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
7,
Submit within 30 days of completion to Division of Water Quality - Infor�,n Prr ssing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone [phone] ��1Yi11
Form GW-la
Rev 2/09
FEB 2 1 2013