383869_Well Construction - GW1_20101201

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
g WATER ZONES (depth)
Top Bottom Top Bottom
Top Bottom Top Bottom
CLYDE SAWYERS AND SON WELL DRILL Top Bottom Top Bottom
Well Contractor Company Name
14885 HWY 209
Street Address
Thickness/
7 CASING Depth Diameter Weight Material
Top +1 Bottom 60 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 Matenal Method
2 WELL INFORMATION Top 0 Bottom 20 Ft CEMENT POURED
WELL CONSTRUCTION PERMIT# 2010-00490 Top Bottom Ft
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply Le
DATE DRILLED 10-27-2010
TIME COMPLETED 10 30 AM [1 PM 0
4 WELL LOCATION
cITY candler COUNTY BUNCOMBE
20 RIDGE TOP ACRES CANDLER NC 28716
(Street Name Numbers, Community Subdivision Lot No Parcel Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑Slope ❑Valley ❑Flat OfRidge ❑Other 11 DRILLING LOG
Top Bottom
LATITUDE 35 575 eel 0000 " DMS OR 3x xxxxxxxxx DD 0 / 60 FT
LONGITUDE 82
° 71 any 0000 " DMS OR 7x XXXXXXXXX DD
Latitude/longitude source [ PS DTopographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5 WELL OWNER
VICKIE KISSELBURG
Owner Name
20 RIDGE TOP ACRES CANDLER, NC 28716
Street Address
CANDLER NC 28715
City or Town State Zip Code
(828 ) 667-3825
Area code Phone number
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
Formation Descnption
OVER BURDEN
60 FT / 105FT GRANITE
/
/
6 WELL DETAILS
a TOTAL DEPTH 105FT
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO II
c WATER LEVEL Below Top of Casing 20 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 variance in accordance with 15A NCAC 2C 0118
e YIELD (gpm) 30 FT METHOD OF TEST RIG
f DISINFECTION Type PILLS Amount 8
/
U V
DEC, g 2010
Infmrridtrarr ft-ocessmgtrntt
12 REMARKS DWQ/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
PRQVIDED TO THE ELL OWN
11-04-2010
SIGNATURE OF CERTIFIED W; L CCbNTRACTOR DATE
DERRICK SCOTT LEDFORD
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