390180_Well Construction - GW1_20101223

( 828 ) 665-2022
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
390180
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
Street Address Top +1 Bottom 110 Ft 6 25" #21 PVC
HOT SPRINGS NC 28743 Top Bottom Ft
City or Town State Zip Code Top Bottom Ft
Area code Phone number 8 GROUT Depth Material Method
2 WELL INFORMATION Top 0 Bottom 20 Ft CEMENT POURED
WELL CONSTRUCTION PERMIT# 2010-00107 Top Bottom Ft
OTHER ASSOCIATED PERMIT#(rf applicable) Top Bottom Ft
SITE WELL ID #(if applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply [{
DATE DRILLED 04-30-2010
TIME COMPLETED 1 30 AM ❑ PM Ei
4 WELL LOCATION
CITY LEICESTER COUNTY BUNCOMBE
MOUNT SOMA LOT 102
(Street Name, Numbers, Community, Subdivision Lot No , Parcel Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropnate box)
DSlope ❑Valley ❑Flat ft Ridge ❑Other
LATITUDE 35 65 645 0000 DMS OR 3x XXXXXXXXX DD
LONGITUDE 82 86671 0000 „ DMS OR 7x XXXXXXXXX DD
Latitude/longitude source li3PS ['Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5 WELL OWNER
GEORGE J EVANS
Owner Name
P O BOX 212
Street Address
TRUMANSBURG
City or Town
425 ) 417-4771
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 905
NY 14886
State Zip Code
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO L�
c WATER LEVEL Below Top of Casing 80 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 variance in accordance with 15A NCAC 2C 0118
e YIELD (gpm) 1 1/2 METHOD OF TEST RIG
f DISINFECTION Type PILLS Amount 25
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 /110FT
Formation Description
OVER BURDEN
110 FT/905 FT GRANITE
/
/
12 REMARKS
Rruin is
ti Boor
DEC 2 3 2010
tivATEr
I r
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS R ; ORD HAS BEEN
PROVIDED TO THE WELL 0 NER
11-23-2010
SIGNATURE OF CER IFIED WELL CONTRAOR DATE
DERRICK HEATH SAWYERS
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to Division of Water Quality - Information Processing, Form GW-la
TMS 2/09
1617 Mail Service Center, Raleigh, NC 27699-161, Phone [phone]
FEB 2 1 2013