390179_Well Construction - GW1_20101223

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 4022-A
1 WELL CONTRACTOR
DERRICK SCOTT LEDFORD
Well Contractor (Individual) Name
CLYDE SAWYERS AND SON WELL DRILL
Well Contractor Company Name
14885 HWY 209
Street Address
HOT SPRINGS
City or Town
( 828 ) 665-2022
Area code Phone number
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT# 2010-00498
NC 28743
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply Il f
DATE DRILLED 10-18-2010
TIME COMPLETED 1 30 AM 0 PM EMI
4 WELL LOCATION
cm, LEICESTER COUNTY BUNCOMBE
MOUNT SOMA LILA LANE
(Street Name Numbers Community Subdivision Lot No Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑Slope ❑ Valley ❑Flat VRidge ❑ Other
LATITUDE 35 65 876 0000 DMS OR 3x xxxxxxxxx DD
LONGITUDE 82 86 422 0000 DMS OR 7x xxxxxxxxx DD
Latitude/longitude source I 3PS ['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 NC 28746
City or Town State Zip Code
(828 ) 712-9944
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 1005
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO Lc
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 vanance in accordance with 15A NCAC 2C 0118
e YIELD (gpm) 1/2 METHOD OF TEST RIG
f DISINFECTION Type PILLS Amount 30
3.90179
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 21 Ft 6 25" #21 PVC
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Material Method
Top 0 Bottom 20 Ft CEMENT POURED
Top Bottom Ft
Top Bottom Ft
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 Description
OVER BURDEN
21 FT / 1005 FT GRANITE
/
12 REMARKS
U a tI nr d v vv... ,m.
DEC 232010
*R r - "\' !Ai 1TY SE.C1`:ON
rinfnrt ✓ G' r'rOCC sstny u""
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 H/}S BEEN
PROVIDFJrO THE WELL OV)/DIER
SIGNATURE OF CERTIFIED WELL
DERRICK SCOTT LEDFORD
11-23-2010
DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to Division of Water Quality. 1pfgation Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone [phone] d �aaa
Form GW-la
Rev 2/09
APR 0 1 2013