384558_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
( 824 258-8496
Area code Phone number
2 WELL INFORMATION: ,
WELL CONSTRUCTION PERMIT# .0 C0C JfD YL
OTHER ASSOCIATED PERMIT#(A applicable)
SITE WELL ID #(it applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply [�
DATE DRILLED "9 /`"Y " j12
TIME COMPLETED J • il AM 0 PM
4. WELL LOCATION
CITY 4ees!�=
COUNTY'n ,md
(Street Name Numbers, Community Subdivision Lot No Parcel Zip Code)
TOPOGRAPHIC / LAND SETTING�TI(check appropnate box)
0 Slope ❑Valley ID Flat L3rcrdge 0 Other
LATITUDE 36 °�1 ' r� �� "DMS OR 3X.XXXXXXXX0( DD
LONGITUDE 75 ° /D3 D2 ' " DMS OR 7X XXXXXXXXX DD
Labtude/longitude source E33PS propographic map
(location of well must be shown on a USGS topo map andaltached to
Ma form If not using GPS)
firrLLOWN
( ea r L-f J�rri E-S
rerNra)
t Address
f4- haler IY..0 off)74/
City or Town State Zip Code
($2..) 6.' 3- .563 f
Area code Phone number
6 WELL DETAILS ���
a TOTAL DEPTH
b DOES WELL REPLACE EXISTING WELL? YES 0 NO
c WATER LEVEL Below Top of Casing / ° 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) METHOD OF TESTB 1 OW 1 ng—Ri g'
f. DISINFECTION Type Chlorine Amount /3 Wiz.
g WATER ZONES (depth)
Top /f-r' Bottom Top om
Top r Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7 CASING Depth Diameter Weight Material
Top 9 Bottom 'a0 Ft 6�Z.S" Se-2'e' /
3u `558
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
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
® / qr
ri 5— / /Ov
/
/
Size Material
Formation Descnpbon
A y
5<4 //
/
1 cur: 16 2010
/ inform
/ Day rocessinV Una
Q/acx;
12 REMARKS
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
1
SIGNATURE OF CERTIFIED WELL CONTRACTOR
/?;;, A UdPief
DATE
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-1 a
Rev 11/08