386218_Well Construction - GW1_20100812

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
326218
g. WATER ZONES (depth)
Top Bottom 3w Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
2731 New Leicester Hwy.Thickness/
7 CASING Depth �t D meter Weight Material
Street Address Top Bottom A 3 Ft ! i r� 5 2-f(oi P.S Od c S'72Z/
Leicester, NC 28748 Top Bottom Ft
City or Town State Zip Code Top Bottom Ft
( 828) 258-8496
Area code Phone number 8 GROUT Depth Material Method
2 WELL INFORMATION II ..,,lJ �� Top 0 Bottom 20 Ft Concrete Gravity -Flow
WELL CONSTRUCTION PERMIT# lI� �� VO`U Top Bottom Ft
OTHER ASSOCIATED PERMIT#(A applicable) Top Bottom Ft
SITE WELL ID #(if applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply Ery
DATE DRILLED b 7eSr i°
1TIME COMPLETED i 30 AM 0 PM
4 WELL LOCATION.
CITY Fe Vj eb4.1 COUNTY A.
00f R)rf-Gzd
(Street Name, Numbers, Community Subdivision Lot No Parcel Zip Code)
TOPOGRAPHIC / LAND SETTIN (check appropnate box)
❑ Slope ❑Valley ❑ Flat�dge ❑ Other
LATITUDE 36 °i S .53 ' l//u/ "DMS OR 3X XXXXXXXXX DD
LONGITUDE 75`A ° o�9.�/ " DMS OR 7x XXXXXXXXX DD
Latitude/longitude source PS ['Topographic map
(location of well must be shown on USGS topo map andattached to
this lbnr if not using GPS)
5. WELL " ER12
lSert7OAD R;(141fl'
,! ll�#eet Address
NC_ a 13O
City or Town State Zip Code
bag)
Area code Phone number
6 WELL DETAILS'
a TOTAL DEPTH' 'MS
b DOES WELL REPLACE EXISTING WELL? YES 0 NO p.
c WATER LEVEL Below Top of Casing 312a r 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
e. YIELD (gpm) a.. METHOD OF TEST BlOWiriq—Rig
f DISINFECTION Type Chlorine Amount%d
9. SCREEN. Depth Diameter Slot Slze Material
Top Bottom Ft in in
Top Bottom Ft. in in
Top Bottom Ft in in
10. SAND/GRAVEL PACK*
Depth Slze Material
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
0 / m
(a pi
Formation Description
C/a v
,5 329
/q / z 3 /K
23 / 4
J/,N 3- 2013
12 REMARKS
RECEIVED
AUG i
!I"iwnliouvn i �Jt,:,Ga:Sfj U^.it
DWQ/BOG
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
(`v
SIGNATURE OF`CERTIFIED Wi:LL CONTRACTOR
L /O
DA E
PRINTEDD NAME PERSON CO RUCTING THE WELL
Submlt the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mall Service Center - Raleigh, NC 27699-1617 Phone No. [phone]
Form GW-la
Rev 11/08