387606_Well Construction - GW1_20100920

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # NCWC 2 0 28 —A
1. WELL CONTRACTOR:
Bobby W. Potts
Well Contractor (Individual) Name
Ferguson's Well and Pump, LLC
Well Contractor Company Name
2731 New Leicester Hwy.
Street Address
Leicester,
NC
28748
City or TOvin State Zip Code
( 828) 258-8496
Area code Phone number
2. WELL INFORMATION: / - t
WELL CONSTRUCTION PERMIT# W C I �d b —UO 3 5e
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID *or applicable)
3 WELL USE (Check Applicab() Residenbal Water Supply 01
o
C1"
DATE DRILLED
2
TIME COMPLETED i/; 3(% AM PM ❑
4. WELL LOCATION..
CITY Le/Ilce,,,,/ COUNTY A.//k()M6---
r�ti. e� "ou )Cif/
(Street Na Numbers, Commun , Subdivision, Lot No Parcel Zip Code)
TOPOGRAPHIC / LAND SETTING- (check appropnete box)
❑ Slope (Valley ❑ Flat Ridge ❑ Other
LATITUDE 36 3S' /" S rS " DMS OR 3X.XXXXXXXXX DD
LONGITUDE 75 /% ° 50 ' 2 (J " DMS OR 7x )00000 00C DD
LabtudeAongitude source PS propographic map
(location of wag must be shown on a USGS topo map andattached to
this form Ifnot using GPS)
5. W 3.I. OWNER `
( .h62Lt G2/114
Owner Name
y/ �l,/o Road
t Address
rheadto a88a.3
City or Town State Zip Code
Area code Phone number
6 WELL DETAILS'
a TOTAL DEPTH' 7A.S
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO Er--
c WATER LEVEL Below Top of Casing 2Q() 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 1SA NCAC 2C 0118
e. YIELD (gpm) (D METHOD OF TEST Blowi nci-Ri g
f. DISINFECTION Type Chlorine Amount 30c '2,_.- , PRINTETI
g. WATER ZONES (depth)
Top Bottom 5')
Top Bottom ;ka()
Top Bottom
7. CASING: Depth Diameter
Top l% Bottom j Ft _`____
Top Bottom Ft
Top Bottom Ft
Top Bottom
Top Bottom
Top Bottom
Thickness/
Weight Material
2_/ 1/- ,fdc 5,0
8 GROUT Depth Material Method
Top 0 Bottom 20 Ft Concrete Gravity -Flow
Top Bottom Ft
Top Bottom Ft
9. SCREEN: Depth Diameter
Top Bottom Ft in
Top Bottom Ft. n
Top Bottom Ft in
10 SAND/GRAVEL PACK:
Depth
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
Size
Slot Size Material
in
in
in
Maternal
11 DRILLING LOG
Top /_ Bottom F Descnption
/ c °rmctk( y L.
3 s S cpi� fcr.<.
f
30 / 7 5 �IV/
12 REMARKS
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
F CE TIFIED ELL C NTRACTOR r�ATE
N CO UC�7�tNG.TME/WELD
W�
PER
v
Submit the original to the Division of Water Quality within 30 day„ Attn: mutton Mgt, S E P 2 0 2010 Form GW-1 a
1617 Mall Service Center - Raleigh, NC 27699-1617 Phone No. (919) k 4 201 Information Processing Unit
11/0Unit
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