388609_Well Construction - GW1_20100101

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolma Department of Environment arrd 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. f,
WELL CONSTRUCTION PERMIT* LDS n 2-6a �D c2 b
OTHER ASSOCIATED PERMIT#(Apppccable)
SITE WELL ID #(If appbcabe) /
3 WELL USE (Check Applicable Box) Residenbal Water Supply [3
DATE DRILLED ti-1"2 S �G7 /
TIME COMPLETED 3' AM ❑ PM Q
4 WELL LOCATION:
CITY le-GLrSty
/�v3e /;// /�/� �s/,•.;,.
COUNTY F4,4/9.A•�C
(Street Name Numbers, Community Subdivision, Lot No Parcel, Zip Code)
TOPOGRAPHIC / LAND SETT)NG (check appropriate box)
❑ Slope [Valley ❑ Flat erRidge ❑Other
LATITUDE 36 "37 ' A/(14' ' DMS OR 3X.)000000xx DD
LONGITUDE 75 " 44' 2/2. " DMS OR 7x XXXXXXXXX DD
Latitude/longitude source PS ()Topographic map
(location of we" must be shown on a USGS topo map andatfadred to
this ram if not using GPS)
8-WELL OWNER /)
VOC e l PlaWt1h100
AW/v7J
/k/((LE /- at
Street Address
Fs ft7 /Uc 7412
City or Town / State Zip Code
7737
Area code Phone number
8 WELL DETAILS
a TOTAL DEPTH' V 64)r
b DOES WELL REPLACE EXISTING WELL? YES 0 NO V
c WATER LEVEL Below Top of Casing /00 FT
(Use "+" it 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 variance in accordance with 15A NCAC 2C 0118
e YIELD (gpm) <rJ METHOD OF TESTB10wing—Rig
f. DISINFECTION. Type Chlorine Amount /4) "
3 8f,09
g. WATER ZONES (depth)
Top 35) Bottom Top Bottom
Top f /{'0 Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASINO. Depth Diameter Weight Material
Top 0 Bottom /3b' Ft ei1J— ,5,,,,ecl .v✓C,
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
/ /3 )
/113/ /31r
Y
/
/
/
12 REMARKS
Size
Material
Formation Descnption
ciy
544
,torrnAtion PrOcebb612 i Ir11t
ONNUril3C
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 DATE
PRINTED NAME OF PERSON CONST U
SHE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Irl 011'� "�� + '� MOAN 0 8 2013
1617 Mall Service Center - Raleigh, NC 27699-1617 Phone No. (919) 907-30QAN 0 4 2013
Form GW-la
Rev 11/08