387610_Well Construction - GW1_20100101

.Rs1
City or Town State Zip Code
Stag ► 113 - ,A(078
Area code Phone number
8 WELL DETAILS'
a TOTAL DEPTH. '%1S
b DOES WELL REPLACE EXISTING WELL? YES 0 NO
c WATER LEVEL Below Top of Casing 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 15A NCAC 2C 0118
10. SAND/GRAVEL PACK.
Depth
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top
3k
/
Bottom
/
12 REMARKS
Size Material
Formabon Descnpbon
lay
SQ4dj711u,,�
/tc/C.
Ci/Vt uJi
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
/OWN ER
f /
SIGNATURE.OF CERTIFIED
e. YIELD (gpm) . METHOD OF TEST BlOWi ncr-Ri g
f. DISINFECTION. Type Chlorine Amount Z '0 Z.
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # NCWC 2 0 2 8 —A 3 8 7 61 of
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 8 GROUT Depth Material Method
2.WELLINFORMATION: Top 0 Bottom 20 Ft Concrete Gravity -Flow
WELL CONSTRUCTION PERMIT# Lt 1 E l 2,Ol 0 •UO 3..L1 Top Bottom Ft
g. WATER ZONES (depth)
Top Bottom .200 Top Bottom
Top Bottom 3 LL Top Bottom
Top Bottom Top Bottom
Thickness/
Diameter Weight Material
3Z Ft ilAS /jd/IZS / cCp/21/
7. CASING: Depth
Top 0 Bottom
Top Bottom Ft
Top Bottom Ft
OTHER ASSOCIATED PERMIT/Kit applicable)
SITE WELL ID Sod applicable)
Top Bottom Ft
9. SCREEN. Depth Diameter Slot Stye Material
3. WELL USE (Check Applicable Box) Residenbal Water Supply V Top Bottom Ft in in
DATE DRILLED 77/3//d Top Bottom Ft. in in
TIME COMPLETED 2.; (% C AM p PM V Top Bottom Ft in in
4. WELL LOCATION.
CITY *511 CUl y /c COUNTY A/A CO M h -
ll(/a yA/ c 5-04 tlG
(Street Name Nu bars Community, Subdivision, Lot No Parcel, Zip Code)
TOPOGRAPH / LAND SETTING (check appropriate box)
❑ Slope alley ❑ Flat D Ridge ❑Other
LATITUDE 36 ,S " (v? ' `if2l- DMS OR 3X.XXXX0000X DD
LONGITUDE 75T1.-e3 / ' /yak 1. " DMS OR 7x XXXXXX 00( DD
Labtudellongitude source LAPS propographlc map
(location awed must be shown on a USGS topo map endefeched to
this form ifnot using GPS)
5. WELL OWN
41
9� 'n;'e�r Name �—�
t,7 t'o.�i � Lie r v reL: DZl l V e
aI1
4treet Address
�i%o
CONTRACTOR
AV" 1 ✓>�...�� B AIL a
A OF PERSON C CT NG E WELL'
PRItsg N IM t l L_LE a
Submit the original to the Division of Water Quality within 30 days. Attn: 1 ' ` tn Mgt", S E P 2 0 2010 Form Gw-1a
1617 Mall Service Center - Raleigh, NC 27699-1617 Phone No. (919) 807-8 11/08
AN 0 9 2013 Information Proocessing Unit