387357_Well Construction - GW1_20100914

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
. t+
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 0 Bottom 82 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# 2010-00332 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 Vi
DATE DRILLED 08-25-2010
TIME COMPLETED 12 00 AM I1 PM ❑
4 WELL LOCATION
CITY LEICESTER COUNTY BUNCOMBE
MINK FARM ROAD LEICESTER N C
(Street Name Numbers Community Subdivision Lot No Parcel Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑Slope ❑Valley ❑Flat ftRidge DOther
LATITUDE 35 so sss o000 DMS OR 3x XXXXXXXXX DD
LONGITUDE 82 • 66611 0000 DMS OR 7x xxxxxxxxx DD
Latitude/longitude source VQPS Dfopographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5 WELL OWNER
MARK FORD
Owner Name
MINK FARM ROAD
Street Address
LEICESTER
City or Town
828 ) 231-8601
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 205 FT
9 SCREEN Depth Diameter Slot Size Material
Top Bottom Ft in 1n
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 /82
Formation Description
OVER BURDEN
82 /205 FT GRANITE
117
/ UEC S J
/
NC /
State Zip Code
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO V
c WATER LEVEL Below Top of Casing 30 FT 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) 3 METHOD OF TEST RIG
f DISINFECTION Type PILLS Amount 8
/
12 REMARKS
rDc -'P-! ! D
5t� 1 4 201n
pSG Untt
inroiniatDfWQ/BOG
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
i//dlild � 09
SIGNATURE OF CE TIFIED WELL CONT CTOR DAA2010
TE
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