388608_Well Construction - GW1_20100101

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolma Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # NCWC 2 0 2 8 —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 Town State Zip Code
( 828) 258-8496
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# laJE/ .0760 4--6 0 4 a -
OTHER ASSOCIATED PERMIT/kit applicable)
SITE WELL ID SRN applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply d/
DATE DRILLED 9/oeio
TIME COMPLETED /0.3 D AM.' PM 0
4. WELL LOCATION.
CITY //`i%/f Ui
COUNTY 4yAc DH D A-
Ca0v c C.tt< ki
(Street Name Numbers, Community, Subdivision, Lot No Parcel Zip Code)
TOPOGRAPHIC / LAND ING (cheek appropnete box)
❑ Slope o Valley Tat ❑Ridge ❑Other
LATITUDE 38 35 ° 'g $Y1 . DMS OR 3X.X000000X DD
LONGITUDE 751 _ ° 24 S " DMS OR 7x X)(3o(XXXXX DD
Labtudefong$tude source PS Oropographic map
(Ioeffian of well must be shown on a USGS topo map andattached to
this form If not using GPS)
5 WELL OWNER
8ti 3UO8
e➢
g. WATER ZONES (depth)
Top Bottom 2 y $ Top Bottom
Top Bottom y&D Top Bottom
Top Bottom Top Bottom
Thic
kness/
7. CASING. Depth Diameter Weight Material
Top_• Bottom c5 8 Ft G/AS Z/l, %.a ,ag,..S"),,AR4
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth
Top 0 Bottom 20
Top Bottom
Top Bottom
Material Method
Ft Concrete Gravity —Flow
Ft
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
Formabon Descnpbon
0 / Ve) ('.fait
S rii�d°ve
/4
Si).
, is
r Name
1 Q 54' TrcliP1/sm-nl.! I IIP 0( Si t-�e
$) 80 / a_55 7
Area code Phone number
6 WELL DETAILS'
/
a TOTAL DEPTH. S0 ,N
Street Address 1
�'S 1el1t UP _ L 322c3
City or Town State Zip Code
b DOES WELL REPLACE EXISTING WELL? YES 0 NO C�'
c. WATER LEVEL Below Top of Casing Ov 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 vananoe in accordance with 15A NCAC 2C 0118
e. YIELD (gpm) j 0� METHOD OF TEST Blowin —Ri g
f. DISINFECTION. Type Chlorine Amount z-
Submit the original to the Division of Water Quality within 30 days. Attn: Information'
1617 Mall Service Center - Raleigh, NC 27699-1617 Phone No. (919) 807-300 JAM I) 4
12 REMARKS
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tRF GEN ED
►Svc. _ R 7.U1U
tntorinotior Processing
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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 0 N R
SIG TUR - OF CERTIF Ti ' D W L CONTRACTOR / DA
(/ 0 ' I `_
PRINTED NA OF P ;: ,!. O NSTRRUCTTING THE WELL
TMS
Form GW-1 a
Rev 11/08
08ann