387609_Well Construction - GW1_20100101

.RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # NCWC 20 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
( 828) 258-8496
Area code Phone number
2. WELL INFORMATION: / %
WELL CONSTRUCTION PERMITS W E/ ,RO/D— b/5V0R
OTHER ASSOCIATED PERMIT#(itapplicable)
SITE WELL ID tli(it apphcabe)
3. WELL USE (Check Applicable Box) Residenbal Water Supply
DATE DRILLED y//40
TIME COMPLETED Z i 3 ) AM 0 PM
4. WELL LOCATION.
CITY Aka Veil(/' WC_ COUNTY !7(Inrr9M be
Zip Code
(Street Name Numbers, Community, Subdivision, Lot No Parcel, Zip Code)
TOP GRAPHIC / LAND SETTING (cheek eppropnate box)
L Iope ❑Valley ❑Flat ❑Ridge, ❑ Olher
LATITUDE 36 35 " Ye 1 zY ' DMS OR 3X.XXXXXXXXX DD
LONGITUDE 75 714,31 07Y' " DM OR 7x xxmrYx xx DD
Latitude/longitude source 206(JTopographic map
(Ibcetan of well roust be shown on a USGS topo map andaftached to
this firm %not using GPS)
5. liNELL OWNER
,yid- /4'4
Ay G
Owner Naar /
, C. C0ti 0)6,4, #i a
S+� t Address toki vu./UC ?9727
City or Town State Zip Code
7�I? 3
Area a code Phone number
6 WELL DETAILS'
a TOTAL DEPTH' 3g
b DOES WELL REPLACE EXISTING WELL? YES 0
c WATER LEVEL Below Top of Casing /OW%
(Use "+" If Above Top of Casing)
d. TOP OF CASINO IS 1 FT Above Land Surface"
"Top of casing terminated at/or below land surface may require
a vanance in accordanceor1with 15A NCAC 2C 0118
3u e. YIELD (gpm) METHOD OF TEST Blowing -Rig
f. DISINFECTION Type Chlorine Amount ZYnZ-
NOL�
FT
g. WATER ZONES (depth)
Top Bottom WS" Top
Top Bottom Top
Top Bottom Top
7. CASINO Depth
Top 0 Bottom Q
Top Bottom
Top Bottom
8 GROUT Depth
Top 0 Bottom 20
n+'i
Bottom
Bottom
Bottom
Thickness/
Diameter Weight Materiel
Ft(pr 3 Z./bias ,1#Csir
Ft
Ft
Ft
Top Bottom Ft
Top Bottom Ft
Material Method
Concrete Gravity -Flow
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
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
7S /Q11
9d / CS
qs / 3$s
12 REMARKS
Size Material
Fo tIon Description
(_(av
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
SIGNA OF CEF2TIFIED
PRINTED NAME OF PE
Submit the original to the Division of Water Quality within 30 days. Attn: Info
1617 Mall Service Center - Raleigh, NC 27699-1617 Phone No. [phone]
ELL CONTRACTOR ATE
W fEL)
9 9t SEP 2 0 2Rev flt 1G1 /08W-1a
201information Processing Unit