383053_Well Construction - GW1_20100507

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# t,()E 1 A001 U05 /ry
3
OTHER ASSOCIATED PERMIT#(ir applicable)
SITE WELL ID :Rif applicable)
3 WELL USE (Check Applicttile Box)
DATE DRILLED Y//,,Vll3
TIME COMPLETED (13i i /I
g. WATER ZONES (depth) ,
Top Bottom /20 Top Bottom
Top Bottom oy / Top Bottom
Top Bottom Top Bottom
Thickness/
7 CASING Depth �/ Diameter Weight Material
4" Top 0 Bottom Ft 6 , Xs L!dl PaCsi)42,/
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth
Top 0 Bottom 20
Ft
Top Bottom Ft
Top Bottom Ft
Material
Concrete
Method
Gravity -Flow
Slot Size Material
Residential Water Supply
in
PM L
4 WELL LOCATION. CITY /-/S4 P t/l' fie e COUNTY,A/M t0,n /f 4 ,
l+1/ C 64 e
(Street NanYe Numbers Community, Subdivision, Lot No , Parcel Zip Code)
TOP APHIC / LAND SETTING (check appropnate box)
lope (Valley 0 Flat 0 Ridge 0 Other
LATITUDE 36 3 5 ° /5 ' 70' " DMS OR 3x XXXxxxxxx DD
LONGITUDE 75 Et.). ° PS " DMS OR 7X XXXXXXXXX DD
Latitude/longitude source PS DTopographic map
(location of well must be shown on a USGS lopo map andatlached to
this form if not using GPS)
6(, Nj'v s, odi�l4 d/!b1 n-As% u,i
Owner Name
. Street Address ,
City or Town f State Zip Code
(?)/9q
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH.
Top Bottom Ft
re. SCREEN. Depth Diameter
b DOES WELL REPLACE EXISTING WELL? YES 0 NO p'
c WATER LEVEL Below Top of Casing - W FT
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS 1 FT Above Land Surfae
'Top of casing terminated at/or below land surface may require
a vanance in accordance with 15A NCAC 2C 0118
e. YIELD (gpm) /00 METHOD OF TEST Bl owi nq-Ri g
f. DISINFECTION Type Chlorine Amount 30 n Z
Top Bottom Ft in in
Top Bottom Ft in
10 SAND/GRAVEL PACK*
Depth
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
0 l z6
2,4
Sly16fO
/
/
/
/
/
/
12 REMARKS
Size
in
Material
Formation Descnption
Ssa•vi57' ''-.c
Eck
(,:,maw✓7 f
V L= U
M AY f; 2uIU
Inform-A+cr, iuuessmg Unit
ntiv
C
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
F CERT`FIED'W LL CONTRACTOR
/ boomsNAME OF PERSON CONSTRUCTI
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]
FEB 2 5 20 Form GW-1 a
Rev 11/08