387607_Well Construction - GW1_20100101

TOPOGRAP LAND SETTING
0 Slope alley ❑Flat O Ridge
LATITUDE 36 3S° l$
LONGITUDE 75f S i\ ° 3S ' 9 pu
Labtudefongltude source PS
(location of wed must be shown on e
this fonn drat using GPS)
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
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: / / n
WELL CONSTRUCTION PERMIT* /i eI 070/4 —OQ 3 �? 9
OTHER ASSOCIATED PERMIT#(it app cable)
SITE WELL ID #(it applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply
DATE DRILLED q/.�//0
TIME COMPLETED (/ /30 AM ❑ PM l�
4. WELL LOCATION:
CITY LI/� /i/ COUNTY AM( d M
(Street Name, Numbers, Community, Subdivision, Lot No Parcel, Zip Code)
(check appropriate box)
❑ Other
D " DMS OR 3X XXXXXXXXX DD
" DMS OR 7X XXXXXXXXX DO
*Topographic map
USGS topo map andaUliched to
5. WE L OWNER
TY1g t I'S�eS A (,�11 NPi
_
It5 r rIra rhwood Quenu.t°
poet Address
OA Cif /v( % a
City or Town State Zip Code
( g??) 3S1- g043
g. WATER ZONES (depn
Top Bottom /�1 a Top Bottom
Top Bottom 3Z 0 Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top 0 Bottom 3z Ft C.A> Zit,/-.0- DOCSi2,'2/
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Material Method
Top 0 Bottom 20 Ft Concrete Gravity —Flow
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
d /,
l JIB
�/3(/s
Area code Phone number
6. WELL DETAILS'
a TOTAL DEPTH. 3145 /
b DOES WELL REPLACE EXISTING WELL? �YE�S 0 NO C7
c WATER LEVEL Below Top of Casing C.-L/ 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) ./ METHOD OF TEST B i Ow i n — R i g
f. DISINFECTION. Type Chlorine Amount Z.
l'
/
/
/
12 REMARKS
Formabonpescnpbon
C QI
S9A�i%�
9,4-7orid
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
SIGNAT RE OF T IE
�
hAN'
PRI TED OF ERSON CO
WELL, ONTRA(L'TOR ATE
Ntut,15.IWyLLD
Submit the original to the Division of Water Quality within 30 days. Attn I ' = = on Mgt,
1617 Mall Service Center — Raleigh, NC 27689-1617 Phone No. [phone]
JAN 0 9 2013
SEP2020mGw81a
Information Processina Unit