386219_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
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# L,J P( , (0 -DO `d / 9
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID Mir applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply
DATE DRILLED �CQ
TIME COMPLETED ( 3 i Dv AM 0 PM V
4 WELL LOCATION.
CITY /,/' 1% /-C (A.) COUNTY /)(J//l (6,14
Dart 1aj7
(Street Name Numbers, Community Subdivision, Lot No , Parcel, Zip Code)
TOP HIC / LAND SETTING (check appropnate box)
ope ❑Valley ❑l Flat ❑ Ridge ❑ Other
LATITUDE 36 35° 3 NZO " DMS OR 3X XXXXXXXXX DD
LONGITUDE 75 f %1 ° 2,0" DMS OR 7X XXXXXX DD
Labtude/longitude source PS XXXQfopographic map
(location of well must be shown on a USGS tope map andsMached to
this form if not using GPS)
&AEU. OWNER
Jcrern W.f "4Sen di I! c
Owner Name
35L ; 14s L.b.P
Beet Address
i (Ut ei )
City or Town
(8a5.) r7'17 40.9
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH* ( v 5
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) ('9\ METHOD OF TEST Blowin -Rig
f. DISINFECTION Type Chlorine Amount Z'
MC. as73d
State Zip Code
b DOES WELL REPLACE EXISTING WELL? YES
nn❑ NO
L/) FT
Top Bottom
Top Bottom
g. WATER ZONES (depth)
Top Bottom f/C Top Bottom
Top Bottom o?DO Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING. Depth Diameter Weight Material
Top 0 Bottom L$'*- Ft 4 , AS 2 I6 i /oZS (fC 'r
Ft
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
Formatio Descnption
51 / SLY S ale`
I,A P/��
r JJ Jy
/
12 REMARKS
mit; 1 2 Lui
Information Processing Unit
UWLrbUv
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
SIGNATURE OF
PRINTJD
ttl (Or
ERTIFIED ELL • TRACT1 R DA
/v
AME OF/PERSON CONSTRUCTING THE WELL
Submit 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