387363_Well Construction - GW1_20100914

RESIDENTIAL WELL CONSTRZ3CTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2436-A
1 WELL CONTRACTOR
DERRICK HEATH SAWYERS
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 HVVY 209 7 CASING Depth Diameter Weight Material
Top 0 Bottom 112 Ft 6 25" #21 PVC
HOT SPRINGS NC 28743 Top Bottom Ft
City or Town State Zip Code Top Bottom Ft
Street Address
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# 2010-00389 Top Bottom Ft
OTHER ASSOCIATED PERMIT#(if applicable) Top Bottom Ft
SITE WELL ID #(if applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply IIif
DATE DRILLED 8-26-10
TIME COMPLETED 4 00 AM 0 PM
4 WELL LOCATION
cITY ASHEVILLE couNTY BUNCOMBE
LOT 120 AURORA VISTA DRIVE 28806
(Street Name Numbers Community Subdivision Lot No Parcel Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑Slope I'Valley ❑Flat ❑Ridge ❑Other
LATITUDE 35 ° 35 285 0000 DMS OR 3x XXXXXxxxx DD
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 /112
LONGITUDE 82 ° 38 ' f 571 0000 DMS OR 7x XXXXxXXXX DD /
Latitude/longitude source RIPS [Topographic map 112 / 265
(location of well must be shown on a USGS topo map andattached to /
this form if not using GPS) /
5 WELL OWNER
LAQUITA PICKENS /
Owner Name
20 BLAKE DRIVE APT N-8 /
Street Address
ARDEN
City or Town
828 ) 552-1583
NC 28704
State Zip Code
Formation Descnption
OVER BURDEN
GRANITE
DW -AI
Du, ail
/ - F ""i i:_D
/ 14 ZU1R
Area code Phone number 12 REMARKS I, 'orRldUUt, �,ucA
6 WELL DETAILS DWQ/RSin9 Unit
a TOTAL DEPTH 265
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO L'
c WATER LEVEL Below Top of Casing 80 FT
(Use "+" if Above Top of Casing)
d TOP OF CASING IS 1 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) 5 METHOD OF TEST RIG
f DISINFECTION Type PILLS Amount 18
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
SArtn9fiT� G 8-26-10
SIGNATURERE OF OF CERTIFIED ELL C RACTOR DATE
DERRICK HEATH SAWYERS
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone . [phone]
Form GW-la
Rev 2/09