387362_Well Construction - GW1_20100914

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 NC 28743
City or Town
( 828) 665-2022
Area code Phone number
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT# 2010-00282
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply [�
DATE DRILLED 07-19-2010
TIME COMPLETED 4 00 AM 0 PM 31
4 WELL LOCATION
crry asheville
COUNTY BUNCOMBE
24 oinev mtn rd Leicester nc
(Street Name, Numbers Community, Subdivision Lot No Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑Slope wirValley ❑Flat ❑Ridge ❑Other
LATITUDE 35 61 5890000" DMS OR 3x xxxxxxxxx DD
LONGITUDE 82
672 105 0000 " DMS OR 7x XXXXXXXXX DD
Latitude/longitude source GtPS ❑topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5 WELL OWNER
Alex and Kim Carrawav
Owner Name
24 Piney Mtn Rd
Street Address
Leicester
City or Town
(828 ) 683-1386
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 265
nc 28748
State Zip Code
b DOES WELL REPLACE EXISTING WELL? YES 0 NO CAI
c WATER LEVEL Below Top of Casing 40 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 variance in accordance with 15A NCAC 2C 0118
e YIELD (gpm) 8 METHOD OF TEST RIG
f DISINFECTION Type PILLS Amount 13
9
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness)
7 CASING Depth Diameter Weight Material
Top 1 Bottom 97 Ft 6 25" #21 PVC
WATER ZONES (depth)
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 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
+1 /97
Formation Description
OVER BURDEN
97 / 265 GRANITE
12 REMARKS
DFC2to7012
oLI 4 4 2010
Intormatia,i ioGessing Unit
nV'OIRo ,
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
PROVi!1 D TO THE WELL •WNER
08-31-2010
SI MATURE OF CERTIFIED WELL I'N i`'ACT DATE
DERRICK SCOTT LEDFORD
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