383046_Well Construction - GW1_20100507

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. / e�
WELL CONSTRUCTION PERMIT# .JE r: O I t I Vh/,
O A
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3 WELL USE (Check ApplicableDrliBox) Residential Water Suiply
DATE DRILLED 3/ aa.S/i /
TIME COMPLETED ((( z i 361 AM 0 PM$
4. WELL LOCATION �,/
CITY .0tea l'< /vr0(%/►1121/i-COUNTY PPON' /4
3/$5�fw� 9
( treat Name Num rs, Community Subdivision Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropnate box)
aglOpe ❑Valley ❑Flat ❑Ridge ,00ther
LATITUDE , 3 S ° 37 ' 7 / 9 e ' DMS OR 3X XXXXXXXIO( DD
LONGITUDt 5 V IXX
p " DMS OR 7x XXXXXXX DD
Latitude/ongitude source PS Qropographtc map
(locabon of well must be shown on a USGS topo map andattached to
this form if not using GPS)
S WELL OWNER //
-e Do 41 Na/ Iide
Owner Name
?GI Moss R�.d
Street Address
erlde S617 Odle. /V� 287R2.
City or Town State Zip Code
cam, 05 - 37.5,5
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 305
b DOES WELL REPLACE EXISTING WELL? YES 0 NO
c WATER LEVEL Below Top of Casing
(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
e. YIELD (gpm) LI METHOD OF TEST Blowing -Rig
f. DISINFECTION Type Chlorine Amount / 8 b7—
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt., T
1617 Mall Service Center - Raleigh, NC 27699-1617 Phone No. [phone]
Top
Top Bottom Ft
Top Bottom Ft
33046
g. WATER ZONES (depth)
Top Bottom / W2. Top Bottom
Top Bottom Z. 70 Top Bottom
Top Bottom Top Bottom
Thickness)
7 CASING. Depth Diameter Weight Material
Bottom 6g- Ft lv, C Z/6,%J pr(5T ?ZI
8 GROUT Depth Material
Top 0 Bottom 20 Ft Concrete
Top Bottom Ft
Top Bottom Ft
Method
Gravity -Flow
9 SCREEN- Depth Diameter Slot Size Material
Top Bottom Ft in in
Top Bottom Ft in in
Top Bottom Ft in in
10 SANDIGRAVEL PACK -
Depth Size Material
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
/
/
/
/
/
12 REMARKS
Formation m escnption
L, r
w/ <'
Nth
MAY 1)72010
Information Proracc,,,,,
DWQ/BOG J J"
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
3/0
NTRACTOR DAT
?,,0 FT
PRINT D NAME QP PERSON CO STRUCTING THE WELL
2 /A 2013
Form GW-la
Rev 11/08