386449_Well Construction - GW1_20100819

ELC
RESIDENTIAL WELL kQ, STRUCTION RECORD
lib 1 /Mir
North Carolina Department of Environment and Natural Resources-Oivision'of Water Quality
WELL CONTRACTOR CERTIFICATION # 2436-A
1 WELL CONTRACTOR
DERRICK HEATH SAWYERS
Well Contractor (Individual) Name
CLYDE SAWYERS AND SON WELL DRILL
Well Contractor Company Name
14885 HWY 209
Street Address
HOT SPRINGS NC 28743
City or Town State Zip Code
( 828 ) 665-2022
Area code Phone number
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT# 2010-00320
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply ('
DATE DRILLED 07-23-2010
TIME COMPLETED AM 0 PM Ll
4 WELL LOCATION
crrY CANDLER COUNTY BUNCOMBE
LOT # 1 MADELYN RIDGE CANDLER NC 28
(Street Name, Numbers Community Subdivision Lot No Parcel Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑Slope GiValley ❑ Flat ❑ Ridge ❑ Other
LATITUDE 35 54 972 0000 ^ DMS OR 3x XXXXXXXXx DD
LONGITUDE 82 73 319 0000 DMS OR 7x XXXXXXXXX DD
Latitude/longitude source I3PS [Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5 WELL OWNER
CLAYTON HOMES
Owner Name
SMOKEY PARK HWY
Street Address
CANDLER NC 28715
City or Town State Zip Code
(828 ) 667-8701
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 180
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO iRr
c WATER LEVEL Below Top of Casing 40 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) 20 METHOD OF TEST RIG
f DISINFECTION Type PILLS Amount 10
�;
4
g WATER ZONES (depth)
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7 CASING Depth Diameter Weight Material
Top +1 Bottom 127 Ft 6 1/4 #21 PVC
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Material Method
Top O Bottom 20 Ft CEMENT POURED
Top Bottom Ft
Top Bottom Ft
9 SCREEN Depth
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
Diameter Slot Size
in in
in in
10 SAND/GRAVEL PACK
Depth
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
+1 /127
127 /180
12 REMARKS
in
Size
in
Material
Material
Formation Description
OVER BURDEN
GRANITE
AIM 1 5 [.tO iC
Information Nrocessn"y
UVVI /0L"
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
'14'1 1l %/ddd dae 08-03-2010
SIGNATURE OF CERTI IF ED WELL CONTR, CTOR DATE
DERRICK HEATH SAWYERS
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
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