384567_Well Construction - GW1_20100615

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolma Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # NCWC 31 4 0 —A
1. WELL CONTRACTOR:
Brian K. Wines
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
( 8 2 a 258-8496
Area code Phone number
2. WELL INFORMATION. %% �J
WELL CONSTRUCTION PERMIT# t/V t I of 01 o — 6610 8
OTHER ASSOCIATED PERMIT#(d applicable)
SITE WELL ID #(it applicable)
3 WELL USE (Check Applicable Box)
DATE DRILLED 5/3/�D
TIME COMPLETED ' r 3T) AM ❑ PM [�
4. WELL LOCATION
CITY le. ee
Residential Water Supply 17
COUNTY+(.0•tii<iic
(Street Name Numbers Community Subdivision, Lot No Parcel Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑ Slope ❑ Valley 0 Flat &Ridge 0 Other
LATITUDE 36 " S'L' fT7 " DMS OR 3X.X00000xxx DD
LONGITUDE 75 ° y0 ' f /t3 " DMS OR 7x XXXXXXXXX DD
Labtude/longitude source [76'S propographic map
(/ocabon of well must be shown on a USGS topo map andatlached to
this form if not using GPS)
5t. OWNERLL
/ rE 1-krh1p-S 'i'
Rimer Na
,D• 100
Street Address
(2leydnder
City or Town State Zip Code
5& 31
/✓c, ,870/
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH. 7V_
b DOES WELL. REPLACE EXISTING WELL? YES 0 NO ©r
c WATER LEVEL Below Top of Casing 200 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) 11 METHOD OFTESTB10W1ng—Rig'
f. DISINFECTION Type Chlorine Amount ,30 h,.
9.
Top Bottom 750
Top Bottom .5 Ya
Top Bottom
WATER ZONES (depth)
7 CASING Depth
Top t Bottom cep Ft
Top Bottom Ft
Top Bottom Ft
�a
3345
Top Bottom
Top Bottom
Top Bottom
Diameter
8 GROUT Depth Matenal
Top 0 Bottom 20 Ft Concrete Gravity -Flow
Top_ Bottom Ft
Top Bottom Ft
Method
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
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Bottom
Size Material
Formation Descnption
c/e1
//
/ FINED
/ JuIv 5 2010
/
12 REMARKS
Informations Processing Unit
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
SIGNATURE OF CERTIFIED WELL CONTRACTOR ATE
4 e n At W .iE r
PRINTED NAME 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